Biliary - Cholangioscopic Observation of Bile Duct Lesions
Comments: Cholangioscopy was introduced to clinical medicine from early seventies and now this technique is becoming more important in the diagnosis and treatment of various bile duct disease.
In this video, I would like to show you several video clips of cholangioscopy which comprised three different parts.
Cholangioscopic findings of normal bile duct, benign bile duct lesions and bile duct tumor.
For the detection of bile duct lesions, cholangioscopist should be familiar with the normal bile duct findings.
Normal extrahepatic bile duct shows round or elliptical lumen and mucosal surface is smooth.
The vascular pattern is faintly visible.
Normal vasculature of CBD is branching or networking pattern.
The ampullary area shows a tapered narrowing and pinpoint opening into duodenum.
Intrahepatic duct also shows smooth mucosal surface and multiple branching ducts.
The lumen shows a proportional narrowing as cholangioscope goes into the peripheral portion of intrahepatic duct
Bile duct stones or repeated cholangitis can cause post-inflammatory ductal changes.
This patient had multiple intrahepatic stones and after cholangioscopic stone removal, ductal changes are clearly visible.
These are ductal strictures and deformity caused by longstanding intrahepatic stones & cholangitis.
The bile duct lumen is not round but compressed and normal mucosal pattern is disappeared.
Scar contractures are also visible.
This is an example of post-inflammatory mucosal hyperplasia. Ductal mucosa can also be changed after inflammation or stone irritation.
This patient also had multiple CBD & IHD stones and after stone removal, mucosal surface revealed unevenness and minute papillary changes.
During cholangioscopy, the most commonly encountered benign duct lesion would be stones in the biliary tree.
This case shows multiple stones and sludge material in the extrahepatic duct.
Large stones should be fragmented before removal and for stone fragmentation, electrohydraulic lithotripsy is commonly used.
This is electrohydraulic lithotripsy, the tip of EHL probe is targetting a large stone and shockwave is generated causing stone fragmentation.
Common biliary parasites are Clonorchis sinensis, Ascariasis and Fasciola hepatica.
This is a small creature trying to reach the opposite side of bile duct wall by elongating oral sucker. It is Clonorchis sinensis.
Occasionally, we can observe larger and more vivid creature in the bile duct, Fasciola hepatica.
Fasciola hepatica is about 2 or 3 times larger than Clonorchis sinensis and easily causes obstruction of biliary tree and secondary cholangitis.
The adult worm is removed by a biopsy forcep and still shows waving movement outside of the body.
Bile duct tumors show an obstructing mass, and irregular mucosa.
Tumor vessel which is defined by irregularly dilated and tortuous neovascularization is an important indicator of malignant stricture.
This patient showed several hyperemic areas with surface irregularity. But the lesions are arrayed in a linear fashion and these are pressure necrosis caused by tube placement. Sometimes iatrogenic lesion may look like true pathology.
I hope this video may be helpful for the cholangioscopic differential diagnosis of bile duct lesions.
| Contributed by: |
Dong Wan Seo, M.D. Physician University of Ulsan, Korea Sang Soo Lee, MD University of Ulsan, Korea Sung Koo Lee, MD University of Ulsan, Korea Myung Hwan Kim, MD University of Ulsan, Korea |
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Citation: Seo, DW & Lee, SS & Lee, SK & Kim, MH (May 21 2007). Biliary - Cholangioscopic Observation of Bile Duct Lesions. The DAVE Project. Retrieved Sep, 8, 2010, from http://daveproject.org/viewfilms.cfm?film_id=594 Times viewed since Feb 2006: 7416 |
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