PROCEDURES PERFORMED:
- ERCP, sphincterotomy and balloon sweep.
- Endoscopic ultrasound with fine needle biopsy.
PREOPERATIVE DIAGNOSES:
- Elevated liver enzymes.
- Enlarged gastrohepatic ligament lymph node on CT scan.
POSTOPERATIVE DIAGNOSES:
- Mildly dilated common bile duct.
- Normal pancreatogram.
- Enlarged gastrohepatic ligament lymph node.
ENDOSCOPIST: John Doe, MD
REFERRING PHYSICIAN: Jane Doe, MD
INDICATION FOR PROCEDURE: This is a (XX)-year-old gentleman with ulcerative colitis and sciatica, arthritis, who was recently started on Humira for treatment of his sciatica, arthritis, and noticed that he did not do well after he received his first injection. His liver enzymes were checked and found to be markedly abnormal with his total bilirubin at 4.2 and his alkaline phosphatase at 488. His transaminases were also mildly elevated. His liver enzymes were repeated 1 week later and his total bilirubin was up to 5.7, but the alkaline phosphatase was at 381. His transaminases had normalized. A CT scan of the abdomen and pelvis was done at the end of September and demonstrated an 8 mm left liver lobe cyst that appeared benign. Incidentally noted was an enlarged gastrohepatic ligament lymph node measuring 2.1 x 1.4 cm. The patient states that his jaundice and darkening of his urine has improved somewhat over the past week. He has also noticed worsening pruritus, particularly at nighttime, over the past several weeks. Also feels that his ulcerative colitis is flaring and he has had increasing diarrhea over the past several weeks. He has not noticed blood in his diarrhea. He has not been complaining of fevers, chills, abdominal pain or weight loss or decreased appetite. He presents today for ERCP to further evaluate his elevated liver enzymes and rule out primary sclerosis and cholangitis and endoscopic ultrasound for further evaluation of his enlarged gastrohepatic ligament lymph node.
CONSENT: The risk, benefits and alternatives of the ERCP, sphincterotomy and balloon sweep was explained to the patient and informed consent was obtained.
MONITORING: Pulse, pulse oximetry, blood pressure, and EKG were monitored throughout the procedure.
MEDICATIONS: Monitored anesthesia care.
TECHNIQUE: The patient was placed in the prone position. The endoscope was passed under direct visualization to the third portion of the duodenum. The gastric contents were suctioned at the beginning and end of the procedure.
FINDINGS: The ampulla appeared normal and was draining bile. Initial attempts at cannulating the common bile duct resulted in obtaining a pancreatogram with half-strength contrast that was normal. Next, the common bile duct was cannulated using a Microvasive Hydratome with preloaded 0.035 inch Hydra Jagwire. Initial cholangiogram with half-strength contrast demonstrated a mildly dilated common bile duct measuring 8 mm with normal intrahepatic bile ducts. There were no obvious filling defects noted within the biliary tract. Due to his recent significant elevation of liver enzymes, it was decided to perform a sphincterotomy.
Next, a generous sphincterotomy was performed using Olympus PulseCut at standard settings. The sphincterotome was then exchanged for a Microvasive 9-12 mm extraction balloon. Next, multiple balloon sweeps were performed without removal of stones or debris. An occlusion cholangiogram with half-strength contrast was then performed with the balloon inflated just above the ampulla and again demonstrated a mildly dilated common bile duct with normal intrahepatic bile ducts and no filling defects within the biliary tract. There was excellent biliary drainage at the end of the procedure and final fluoroscopic images demonstrated excellent drainage of contrast.
The duodenoscope was then exchanged for the radial and linear echoendoscopes. Next, both radial and linear endosonography demonstrated an enlarged lymph node within the gastrohepatic ligament. This lymph node measured 1.8 x 1.2 cm. This lymph node appeared hypoechoic, heterogeneous and irregularly shaped with well-demarcated borders. There was no evidence of celiac lymphadenopathy. The pancreas appeared normal in the head, body, and tail. The pancreatic duct was normal caliber throughout the pancreas. The common bile duct was mildly dilated and measured 8 mm. The gallbladder, portal vein, celiac access and splenic artery and vein all appeared normal.
Next, under endosonographic guidance, utilizing an echo tip trocar 22-gauge needle, fine needle biopsy of the enlarged lymph node in the gastrohepatic ligament was performed. A total of 2 passes were made. Cytopathology was then sent to confirm adequate tissue sampling. The lymph node aspirate was sent for both cytology and flow cytometry.
COMPLICATIONS: None.
SUMMARY:
- Mildly dilated common bile duct with normal intrahepatic bile duct status post sphincterotomy and balloon sweep.
- Normal pancreatogram.
- A 1.8 x 1.2 cm enlarged gastrohepatic ligament lymph node, status post fine needle biopsy.
RECOMMENDATIONS:
- Followup on cytology and flow cytometry results.
- Repeat liver enzymes today.
- Await results of viral hepatitis serologies, which are currently pending.