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Biliary stricture as a complication of chronic relapsing pancreatitis
Biliary Stricture as a Complication of Chronic Relapsing Pancreatitis
Nicolas J. Lygidakis, MD, London, England
Distal common bile duct stricture after repeated episodes of relapsing pancreatitis has just recently been established as a clinical entity [l-4]. Indeed, distal common bile duct involvement through a process of fibrocalcific pancreatitis should be expected, considering the fact that the distal third of the common bile duct transverses the pancreas [5]. Experience with 25 patients who were seen and operated on in Athens, Greece from 1976 to 1981 for chronic relapsing pancreatitis associated with obstructive jaundice due to stricture of a distal common bile duct is reported. Material and Methods Twenty women and 5 men were included in the study. Their ages ranged from 24 to 81 years (mean 48 f 3 years). Length of history of symptoms ranged from 3 to 11 years (mean 9 f 2 years). All 25 patients were part of a series of 92 patients who presented for treatment because of chronic pancreatitis during the aforementioned 4 year period. Clinical presentation: Of the 25 patients, 15 had never drank alcohol and 10 did consume alcohol. None of our patients had gallstones and none had undergone any previous operations. The main clinical symptom that was present in all 25 patients was recurrent attacks of severe upper abdominal pain which radiated to the back. In addition, vomiting due to duodenal obstruction occurred in five patients. Notably, jaundice was present at admission in all 25 patients and there was a mean weight loss of 14 f 2 kg per patient. Other associated symptoms were fatigue and anorexia. All 25 patients had been hospitalized previously (average 5 to 11 times; mean 7 f 2 times) and all had previous episodes of jaundice (mean 8 f 3 episodes). At admission the patients were clinically assessed through a detailed clinical history and physical examination. Routine hematologic and biochemical tests were performed. These included measurement of the hematocrit value, the hemoglobin level, the white blood cell count, and the bilirubin, alkaline phosphatase, serum glutamic oxalacetic transaminase @GOT), serum pyruvic oxalacetic transaminase (SGPT), serum amylase, and serum creatinine levels. In addition, total serum protein and serum albumin globulin ratio determinations were carried out From the Royal Postgraduate Medical School, Hammersmith Hospital, London, England. Requests for reprints should be addressed to Nicolas J. Lygidakis, MD, Royal Postgraduate Medical School, Hammersmith Hospital, DuCane Road, London W 12 OHS, England.
804
in all the patients. The degree of pancreatic calcification was assessed by plain abdominal roentgenography and ultrasonography, both of which were routinely carried out in all 25 patients. Barium meal examinations and endoscopic studies were carried out to rule out duodenal obstruction or distortion in the five patients who presented with vomiting. Finally, the precise anatomy of the biliary tree was assessed by a combination of ultrasonography with either percutaneous transhepatic cholangiography (PTC) (17 patients) or endoscopic retrograde cholangiopancreatography (ERCP) (8 patients). ERCP was not performed in the presence of duodenal obstruction, in patients with increased amylase levels, or in those in whom our ultrasonographic findings (dilated intrahepatic ducts) predicted that PTC would provide good visualization. Thus, of the 25 patients, 17 were seen with dilated intrahepatic ducts and all underwent PTC. Antibiotics were given 12 hours before operation in all the patients and were continued thereafter for the first 5 postoperative days. Gentamycin (80 IU 3 times daily) was our antibiotic of choice. Intraoperative, preexploratory, and postexploratory cholangiography was routinely carried out in all our patients. After operation, all the patients were followed up at yearly intervals. Our follow-up period ranged from 1 to 6 years (mean 5 f 1 years). Eighteen patients were followed for a period of more than 5 years. Follow-up included (1) a personal interview before physical examination to obtain a detailed assessment of the clinical picture of each individual patient, and (2) a series of serum bilirubin, SGOT, SGPT, alkaline phosphatase, and serum amylase determinations. Barium meal contrast studies, endoscopy, and ultrasonography were also carried out. Results were classified grade I, II, III, or IV. Treatment: All 25 patients underwent surgery that included cholecystectomy, choledochotomy, and side-to-side choledochoduodenostomy. In addition, in the five patients with duodenal obstruction, truncal vagotomy and gastrojejunostomy was carried out, and for the four patients with pancreatic pseudocyst, a Roux-Y cystojejunostomy was the procedure of choice.
Results Preoperative
investigations
revealed an increased
white blood cell count in 7 patients (range 12,000 to 19,000 cells/mm3; mean 13,000 cells/mm”), anemia in 4 patients (hemoglobin level below 10 g), increased SGOT and SGPT levels in 17 patients, increased bilirubin and alkaline phosphatase levels in all 25 patients, increased creatinine levels in 3 patients,
The American Journal of Surgery
Biliary Stricture in Pancreatitis
decreased total serum proteins, and an albumin to globulin ratio reversal in 9 patients. Plain abdominal roentgenography revealed pancreatic calcification in nine of the 25 patients, and ultrasonography yielded a diagnosis of intrahepatic biliary dilatation in 17 patients and the presence of a pancreatic pseudocyst in 4 patients. Duodenal obstruction was detected by endoscopy and barium meal contrast studies in the five patients examined by these means. PTC yielded a correct diagnosis in all 17 patients in whom it was used and in whom strictures of the distal third of the common bile duct were found in association with a pronounced dilatation of the proximal biliary tree (Figure 1). ERCP was carried out successfully in all eight patients in whom it was used and also led to the correct diagnosis of distal biliary stricture and proximal biliary dilatation in all. The pancreatic duct was visualized in five of the eight patients. In addition, major pancreatic ductal stricture was seen in three of the five patients. In the other two patients, no pathologic abnormalities in the pancreatic duct were observed. Intraoperative cholangiography confirmed our preoperative diagnosis and demonstrated stricture of the distal third of the common bile duct. Operative results: There were no deaths. Complications included wound sepsis in three patients, respiratory infection in one patient, and deep venous thrombosis in three patients. All complications resolved with conservative treatment. Late results: All patients were followed regularly during our follow-up period. Jaundice or cholangitis did not develop in any of the patients. In addition, serial investigations for bilirubin, alkaline phosphatase, SGOT, and SGPT levels revealed a progressive return towards normal values 3 to 4 years after surgery. The most striking finding, however, was the weight gain and the return to a normal lifestyle and working capacity. None of our patients were readmitted or reoperated on for any reason related to the disease or operation. Hence, there were 20 grade I patients, 3 grade II patients, and 2 grade III patients. Comments From the results of this study, it has been shown that modern preoperative technology is of value in defining any pathologic abnormality in the biliary tree of a patient presenting with chronic relapsing pancreatitis. Indeed, in a condition such as chronic relapsing pancreatitis, the presence of jaundice could easily be attributed to pancreatic edema and swelling, and thus the treatment could be misleading and irrelevant. However, in chronic pancreatitis the main pathologic feature is fibrosis, which leads to a shrunken and deformed gland densely adherent to surrounding strictures, such as the distal end of the common bile duct which transverses this organ. It is for this reason that obstructive jaundice developed
Volume 145, June 1333
Figure 1. Strktwe of the distal third of the common bile duct with an associated pronounced dilatation of the proximal blllaty tree as identified by percutaneous transhepatic cholangiography.
in almost one third of our patients with chronic pancreatitis. These findings are in accordance with a previously reported experience [5]. Nevertheless, the diagnosis of the precise cause of the jaundice, and particularly of distal common bile duct stricture, in patients with recurrent pancreatitis seems to be important not only to achieve successful treatment of a disease, which if untreated might result in serious deterioration of the patient’s general condition and in development of liver cholestatic cirrhosis, but particularly to avoid unnecessary major surgical intervention, such as pancreatectomy. Thus, when dealing with jaundiced patients presenting with chronic relapsing pancreatitis, the presence of stenosis of the retropancreatic portion of the common bile duct should be seriously considered because it does occur in from 9 to 63 percent of patients [6]. However, although the radiologic picture of this abnormality is characteristic (hourglass deformity or a smooth tapering deformity of the retropancreatic bile duct), it must be precisely differentiated from other pathologic abnormalities. In this respect ERCP might be helpful in demonstrating pancreatic duct
805
Lygidakis
abnormalities that are virtually diagnostic of chronic pancreatitis. In addition, ultrasonography, computerized tomography, and analysis of the clinical picture and natural history of the disease should also contribute to the correct diagnosis. The aforementioned techniques are of value in the diagnosis of pancreatic pseudocyst and pancreatic abscess. Although jaundice may be present, the possibility of the association of a common bile duct stricture should be excluded only when there is evidence obtained by either PTC, ERCP, or interoperative cholangiography. This study has shown that biliary obstruction due to distal common bile duct stricture in patients with chronic relapsing pancreatitis is a disease that might be manageable by a simple and safe procedure such as choledochoduodenostomy. We believe that the presence of jaundice in patients with chronic relapsing pancreatitis should raise the possibility of distal common bile duct stricture, irrespective of any other concomitant finding such as pancreatic pseudocyst or pancreatic abscess. The precise definition of chronic relapsing pancreatitis with biliary stricture seems important and can be made with accuracy by employing ultrasonography, PTC, or ERCP. It is only with a precise diagnosis that the disease can be successfully treated by use of simple surgical procedures such as choledochoduodenostomy which, at least for a large proportion of patients who present with distal common bile duct stricture associated with chronic relapsing pancreatitis, has been shown to offer the most satisfactory results.
806
Summary To assess our results in the treatment of patients who present with obstructive jaundice due to distal common bile duct stricture after chronic relapsing pancreatitis, 25 patients were seen and operated on for this disease between 1974 and 1981. Our results have demonstrated that provided the diagnosis of the disease is accurate, the management for a large proportion of patients can be simple, safe, and effective. Indeed, choledochoduodenostomy, which has been carried out in combination with either gastrojejunostomy and vagotomy in the presence of duodenal obstruction or with pericystojejunostomy for the treatment of pancreatic pseudocyst, has been shown to be the treatment of choice. References 1. Weinstein BR, Kory RJ, Zimmerman HJ. Obstructive jaundice as a complication of pancreatitis. Ann Intern Med 196358: 245-58. 2. McCollum WB, Jordan PH. Obstructive jaundice in patients with pancreatitis without associated biliary tract disease. Ann Surg 1975;182:116-20. 3. Fiteden JH. The significance of jaundice in acute pancreatitis. Arch Surg 1965;90:422-6. 4. Scott J, Summerfield JA, Elias E, Dick R, Sherlock S. Chronic pancreatitis: a cause of cholestasis. Gut 1977;18:196201. 5. Gregg JA, Carr-Locke DL, Gallagher MM. Importance of common bile duct stricture associated with chronic pancreatitis. Am J Surg 1982;141:199-203. 6. Schulte WS, Laporter AJ, Condon RE, Unger GF, Geeven SE, DeCosse JJ. Chronic pancreatitis-a cause of biliary stricture. Surgery 1977;82:303-9.
The American Journal of Surgery
Nicolas J. Lygidakis, MD, London, England
Distal common bile duct stricture after repeated episodes of relapsing pancreatitis has just recently been established as a clinical entity [l-4]. Indeed, distal common bile duct involvement through a process of fibrocalcific pancreatitis should be expected, considering the fact that the distal third of the common bile duct transverses the pancreas [5]. Experience with 25 patients who were seen and operated on in Athens, Greece from 1976 to 1981 for chronic relapsing pancreatitis associated with obstructive jaundice due to stricture of a distal common bile duct is reported. Material and Methods Twenty women and 5 men were included in the study. Their ages ranged from 24 to 81 years (mean 48 f 3 years). Length of history of symptoms ranged from 3 to 11 years (mean 9 f 2 years). All 25 patients were part of a series of 92 patients who presented for treatment because of chronic pancreatitis during the aforementioned 4 year period. Clinical presentation: Of the 25 patients, 15 had never drank alcohol and 10 did consume alcohol. None of our patients had gallstones and none had undergone any previous operations. The main clinical symptom that was present in all 25 patients was recurrent attacks of severe upper abdominal pain which radiated to the back. In addition, vomiting due to duodenal obstruction occurred in five patients. Notably, jaundice was present at admission in all 25 patients and there was a mean weight loss of 14 f 2 kg per patient. Other associated symptoms were fatigue and anorexia. All 25 patients had been hospitalized previously (average 5 to 11 times; mean 7 f 2 times) and all had previous episodes of jaundice (mean 8 f 3 episodes). At admission the patients were clinically assessed through a detailed clinical history and physical examination. Routine hematologic and biochemical tests were performed. These included measurement of the hematocrit value, the hemoglobin level, the white blood cell count, and the bilirubin, alkaline phosphatase, serum glutamic oxalacetic transaminase @GOT), serum pyruvic oxalacetic transaminase (SGPT), serum amylase, and serum creatinine levels. In addition, total serum protein and serum albumin globulin ratio determinations were carried out From the Royal Postgraduate Medical School, Hammersmith Hospital, London, England. Requests for reprints should be addressed to Nicolas J. Lygidakis, MD, Royal Postgraduate Medical School, Hammersmith Hospital, DuCane Road, London W 12 OHS, England.
804
in all the patients. The degree of pancreatic calcification was assessed by plain abdominal roentgenography and ultrasonography, both of which were routinely carried out in all 25 patients. Barium meal examinations and endoscopic studies were carried out to rule out duodenal obstruction or distortion in the five patients who presented with vomiting. Finally, the precise anatomy of the biliary tree was assessed by a combination of ultrasonography with either percutaneous transhepatic cholangiography (PTC) (17 patients) or endoscopic retrograde cholangiopancreatography (ERCP) (8 patients). ERCP was not performed in the presence of duodenal obstruction, in patients with increased amylase levels, or in those in whom our ultrasonographic findings (dilated intrahepatic ducts) predicted that PTC would provide good visualization. Thus, of the 25 patients, 17 were seen with dilated intrahepatic ducts and all underwent PTC. Antibiotics were given 12 hours before operation in all the patients and were continued thereafter for the first 5 postoperative days. Gentamycin (80 IU 3 times daily) was our antibiotic of choice. Intraoperative, preexploratory, and postexploratory cholangiography was routinely carried out in all our patients. After operation, all the patients were followed up at yearly intervals. Our follow-up period ranged from 1 to 6 years (mean 5 f 1 years). Eighteen patients were followed for a period of more than 5 years. Follow-up included (1) a personal interview before physical examination to obtain a detailed assessment of the clinical picture of each individual patient, and (2) a series of serum bilirubin, SGOT, SGPT, alkaline phosphatase, and serum amylase determinations. Barium meal contrast studies, endoscopy, and ultrasonography were also carried out. Results were classified grade I, II, III, or IV. Treatment: All 25 patients underwent surgery that included cholecystectomy, choledochotomy, and side-to-side choledochoduodenostomy. In addition, in the five patients with duodenal obstruction, truncal vagotomy and gastrojejunostomy was carried out, and for the four patients with pancreatic pseudocyst, a Roux-Y cystojejunostomy was the procedure of choice.
Results Preoperative
investigations
revealed an increased
white blood cell count in 7 patients (range 12,000 to 19,000 cells/mm3; mean 13,000 cells/mm”), anemia in 4 patients (hemoglobin level below 10 g), increased SGOT and SGPT levels in 17 patients, increased bilirubin and alkaline phosphatase levels in all 25 patients, increased creatinine levels in 3 patients,
The American Journal of Surgery
Biliary Stricture in Pancreatitis
decreased total serum proteins, and an albumin to globulin ratio reversal in 9 patients. Plain abdominal roentgenography revealed pancreatic calcification in nine of the 25 patients, and ultrasonography yielded a diagnosis of intrahepatic biliary dilatation in 17 patients and the presence of a pancreatic pseudocyst in 4 patients. Duodenal obstruction was detected by endoscopy and barium meal contrast studies in the five patients examined by these means. PTC yielded a correct diagnosis in all 17 patients in whom it was used and in whom strictures of the distal third of the common bile duct were found in association with a pronounced dilatation of the proximal biliary tree (Figure 1). ERCP was carried out successfully in all eight patients in whom it was used and also led to the correct diagnosis of distal biliary stricture and proximal biliary dilatation in all. The pancreatic duct was visualized in five of the eight patients. In addition, major pancreatic ductal stricture was seen in three of the five patients. In the other two patients, no pathologic abnormalities in the pancreatic duct were observed. Intraoperative cholangiography confirmed our preoperative diagnosis and demonstrated stricture of the distal third of the common bile duct. Operative results: There were no deaths. Complications included wound sepsis in three patients, respiratory infection in one patient, and deep venous thrombosis in three patients. All complications resolved with conservative treatment. Late results: All patients were followed regularly during our follow-up period. Jaundice or cholangitis did not develop in any of the patients. In addition, serial investigations for bilirubin, alkaline phosphatase, SGOT, and SGPT levels revealed a progressive return towards normal values 3 to 4 years after surgery. The most striking finding, however, was the weight gain and the return to a normal lifestyle and working capacity. None of our patients were readmitted or reoperated on for any reason related to the disease or operation. Hence, there were 20 grade I patients, 3 grade II patients, and 2 grade III patients. Comments From the results of this study, it has been shown that modern preoperative technology is of value in defining any pathologic abnormality in the biliary tree of a patient presenting with chronic relapsing pancreatitis. Indeed, in a condition such as chronic relapsing pancreatitis, the presence of jaundice could easily be attributed to pancreatic edema and swelling, and thus the treatment could be misleading and irrelevant. However, in chronic pancreatitis the main pathologic feature is fibrosis, which leads to a shrunken and deformed gland densely adherent to surrounding strictures, such as the distal end of the common bile duct which transverses this organ. It is for this reason that obstructive jaundice developed
Volume 145, June 1333
Figure 1. Strktwe of the distal third of the common bile duct with an associated pronounced dilatation of the proximal blllaty tree as identified by percutaneous transhepatic cholangiography.
in almost one third of our patients with chronic pancreatitis. These findings are in accordance with a previously reported experience [5]. Nevertheless, the diagnosis of the precise cause of the jaundice, and particularly of distal common bile duct stricture, in patients with recurrent pancreatitis seems to be important not only to achieve successful treatment of a disease, which if untreated might result in serious deterioration of the patient’s general condition and in development of liver cholestatic cirrhosis, but particularly to avoid unnecessary major surgical intervention, such as pancreatectomy. Thus, when dealing with jaundiced patients presenting with chronic relapsing pancreatitis, the presence of stenosis of the retropancreatic portion of the common bile duct should be seriously considered because it does occur in from 9 to 63 percent of patients [6]. However, although the radiologic picture of this abnormality is characteristic (hourglass deformity or a smooth tapering deformity of the retropancreatic bile duct), it must be precisely differentiated from other pathologic abnormalities. In this respect ERCP might be helpful in demonstrating pancreatic duct
805
Lygidakis
abnormalities that are virtually diagnostic of chronic pancreatitis. In addition, ultrasonography, computerized tomography, and analysis of the clinical picture and natural history of the disease should also contribute to the correct diagnosis. The aforementioned techniques are of value in the diagnosis of pancreatic pseudocyst and pancreatic abscess. Although jaundice may be present, the possibility of the association of a common bile duct stricture should be excluded only when there is evidence obtained by either PTC, ERCP, or interoperative cholangiography. This study has shown that biliary obstruction due to distal common bile duct stricture in patients with chronic relapsing pancreatitis is a disease that might be manageable by a simple and safe procedure such as choledochoduodenostomy. We believe that the presence of jaundice in patients with chronic relapsing pancreatitis should raise the possibility of distal common bile duct stricture, irrespective of any other concomitant finding such as pancreatic pseudocyst or pancreatic abscess. The precise definition of chronic relapsing pancreatitis with biliary stricture seems important and can be made with accuracy by employing ultrasonography, PTC, or ERCP. It is only with a precise diagnosis that the disease can be successfully treated by use of simple surgical procedures such as choledochoduodenostomy which, at least for a large proportion of patients who present with distal common bile duct stricture associated with chronic relapsing pancreatitis, has been shown to offer the most satisfactory results.
806
Summary To assess our results in the treatment of patients who present with obstructive jaundice due to distal common bile duct stricture after chronic relapsing pancreatitis, 25 patients were seen and operated on for this disease between 1974 and 1981. Our results have demonstrated that provided the diagnosis of the disease is accurate, the management for a large proportion of patients can be simple, safe, and effective. Indeed, choledochoduodenostomy, which has been carried out in combination with either gastrojejunostomy and vagotomy in the presence of duodenal obstruction or with pericystojejunostomy for the treatment of pancreatic pseudocyst, has been shown to be the treatment of choice. References 1. Weinstein BR, Kory RJ, Zimmerman HJ. Obstructive jaundice as a complication of pancreatitis. Ann Intern Med 196358: 245-58. 2. McCollum WB, Jordan PH. Obstructive jaundice in patients with pancreatitis without associated biliary tract disease. Ann Surg 1975;182:116-20. 3. Fiteden JH. The significance of jaundice in acute pancreatitis. Arch Surg 1965;90:422-6. 4. Scott J, Summerfield JA, Elias E, Dick R, Sherlock S. Chronic pancreatitis: a cause of cholestasis. Gut 1977;18:196201. 5. Gregg JA, Carr-Locke DL, Gallagher MM. Importance of common bile duct stricture associated with chronic pancreatitis. Am J Surg 1982;141:199-203. 6. Schulte WS, Laporter AJ, Condon RE, Unger GF, Geeven SE, DeCosse JJ. Chronic pancreatitis-a cause of biliary stricture. Surgery 1977;82:303-9.
The American Journal of Surgery