Article Search
검색
검색 팝업 닫기

Metrics

Help

  • 1. Aims and Scope

    Gut and Liver is an international journal of gastroenterology, focusing on the gastrointestinal tract, liver, biliary tree, pancreas, motility, and neurogastroenterology. Gut atnd Liver delivers up-to-date, authoritative papers on both clinical and research-based topics in gastroenterology. The Journal publishes original articles, case reports, brief communications, letters to the editor and invited review articles in the field of gastroenterology. The Journal is operated by internationally renowned editorial boards and designed to provide a global opportunity to promote academic developments in the field of gastroenterology and hepatology. +MORE

  • 2. Editorial Board

    Editor-in-Chief + MORE

    Editor-in-Chief
    Yong Chan Lee Professor of Medicine
    Director, Gastrointestinal Research Laboratory
    Veterans Affairs Medical Center, Univ. California San Francisco
    San Francisco, USA

    Deputy Editor

    Deputy Editor
    Jong Pil Im Seoul National University College of Medicine, Seoul, Korea
    Robert S. Bresalier University of Texas M. D. Anderson Cancer Center, Houston, USA
    Steven H. Itzkowitz Mount Sinai Medical Center, NY, USA
  • 3. Editorial Office
  • 4. Articles
  • 5. Instructions for Authors
  • 6. File Download (PDF version)
  • 7. Ethical Standards
  • 8. Peer Review

    All papers submitted to Gut and Liver are reviewed by the editorial team before being sent out for an external peer review to rule out papers that have low priority, insufficient originality, scientific flaws, or the absence of a message of importance to the readers of the Journal. A decision about these papers will usually be made within two or three weeks.
    The remaining articles are usually sent to two reviewers. It would be very helpful if you could suggest a selection of reviewers and include their contact details. We may not always use the reviewers you recommend, but suggesting reviewers will make our reviewer database much richer; in the end, everyone will benefit. We reserve the right to return manuscripts in which no reviewers are suggested.

    The final responsibility for the decision to accept or reject lies with the editors. In many cases, papers may be rejected despite favorable reviews because of editorial policy or a lack of space. The editor retains the right to determine publication priorities, the style of the paper, and to request, if necessary, that the material submitted be shortened for publication.

Search

Search

Year

to

Article Type

Case Report

Split Viewer

Early Bile Duct Cancer Detected by Direct Peroral Cholangioscopy with Narrow-Band Imaging after Bile Duct Stone Removal

Hyung Ki Kim, Jong Ho Moon*, Hyun Jong Choi, Hee Kyung Kim*, Seul Ki Min, Jong Kyu Park, Young Deok Cho, Sang-Heum Park, and Moon Sung Lee

Digestive Disease Center, Soonchunhyang University School of Medicine, Bucheon, Korea.

*Department of Internal Medicine and Pathology, Soonchunhyang University School of Medicine, Bucheon, Korea.

Correspondence to: Jong Ho Moon. Digestive Disease Center, Soonchunhyang University Bucheon Hospital, Soonchunhyang University School of Medicine, 1174 Jung-dong, Wonmi-gu, Bucheon 420-767, Korea. Tel: +82-32-621-5094, Fax: +82-32-621-5080, jhmoon@schmc.ac.kr

Received: February 26, 2010; Accepted: June 3, 2010

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Gut Liver 2011;5(3):377-379. https://doi.org/10.5009/gnl.2011.5.3.377

Published online August 18, 2011, Published date September 30, 2011

Copyright © Gut and Liver.

Cholangioscopy not only enables the direct visualization of the biliary tree, but also allows for forceps biopsy to diagnosis early cholangiocarcinoma. Recently, some reports have suggested the clinical usefulness of direct peroral cholangioscopy (POC) using an ultra-slim endoscope with a standard endoscopic unit by a single operator. Enhanced endoscopy, such as narrow band imaging (NBI), can be helpful for detecting early neoplasia in the gastrointestinal tract and is easily applicable during direct POC. A 63-year-old woman with acute cholangitis had persistent bile duct dilation on the left hepatic duct after common bile duct stone removal and clinical improvement. We performed direct POC with NBI using an ultra-slim upper endoscope to examine the strictured segment. NBI examination showed an irregular surface and polypoid structure with tumor vessels. Target biopsy under direct endoscopic visualization was performed, and adenocarcinoma was documented. The patient underwent an extended left hepatectomy, and the resected specimen showed early bile duct cancer confined to the ductal mucosa.

Keywords: Early bile duct cancer, Direct peroral cholangioscopy, Narrow band imaging

The early diagnosis of cholangiocarcinoma (CC) is important because surgery is the only curative treatment. Cholangioscopy not only enables direct visualization of the biliary tree, but also allows forceps biopsy to diagnosis early CC.1-3 However, the clinical use of percutaneous3 or peroral cholangioscopy using a "mother-baby scope"1,4,5 is limited because of its invasiveness or inconvenience. Recently, some reports have indicated the clinical usefulness of direct peroral cholangioscopy (POC) using an ultra-slim endoscope5,6 with a standard endoscopic unit by a single operator. Enhanced endoscopy, such as narrow band imaging (NBI), can be helpful for detecting early neoplasia in the gastrointestinal tract.7-9 NBI is easily applied during direct POC using an ultra-slim endoscope. We report a case of early bile duct cancer diagnosed at direct POC with NBI using an ultra-slim endoscope.

A 63-year-old woman was admitted to the emergency room with right upper quadrant pain with fever over 2 days. Laboratory findings were as follows: white blood cell count 14,400/µL, total/direct bilirubin 2.89/2.09 mg/dL, gamma-glutamyl-transpeptidase 1,470 IU/L, and alkaline phosphatase 1,334 IU/L. Abdominal computed tomography showed bile duct dilation and high density stone on ampullary portion (Fig. 1). After the removal of the impacted stone on the ampullary orifice and nasobiliary drainage, clinical symptoms were improved. On the 3rd hospital day, we performed endoscopic retrograde cholangiography (ERC) to evaluate for remnant stones. ERC showed no remnant stone but duct dilation on left hepatic duct and short segment stricture on the orifice (Fig. 2).

We examined the stricture under endoscopic visualization using intraductal balloon-guided direct POC using an ultra-slim upper endoscope (GIF-XP260N; Olympus, Tokyo, Japan) as our previous report.6 The endoscope was inserted into the ampulla of Vater. After advancing the 5 F balloon catheter (MTW Endoskopie, Wesel, Germany) through the stricture via the guidewire, the balloon was inflated to anchor it inside the left hepatic duct. The endoscope was advanced over the balloon catheter into the proximal bile duct using the ropeway method (Fig. 3). We observed the stricture under white light (WL) and NBI (Evis Lucera 260 System; Olympus) examination.

The WL examination showed ill-defined hyperemia at the stricture site. NBI showed better contrast than did the WL examination, with a well-defined margin and prominent, thickened vascular markings (Fig. 4). We performed a target biopsy of the lesion using biopsy forceps (FB-19K-1; Olympus). Histopathological examination revealed a well-differentiated adenocarcinoma. The patient underwent an extended left hepatectomy. Histopathologically, the resected specimen showed focal papillary adenocarcinoma confined to the ductal mucosa (Fig. 5).

Cholangioscopy provides advantages over endoscopic retrograde cholangiopancreatography (ERCP) for the diagnosis of lesions in the bile duct. Visual information from the endoscope disclose characteristics of filling defects or stricture site, which enables us not only to differentiate between benign and malignant strictures, but also to apply treatment or to biopsy in some cases.1 Direct POC with ultra-slim upper endoscope has been proposed as a potential solutions for the direct visual examination of the biliary tree.5 In this case, there were persistent bile duct stricture after stone removal. At present, there are some limitation of the cholangiogram or cytology study including brush cytology to differentiate between benign and malignancy. We evaluated the stricture site by using the direct POC with ultra-slim endocope. It provides white light image of the lesion and NBI, thus enable to target biopsy for proper diagnosis.

The recently introduced NBI is helpful for diagnosing early gastrointestinal neoplasia due to its ability to yield clear images of the surface structure and microvessels.7-9 Although it has not become established in biliary disease, Itoi et al.10 reported the usefulness of NBI for the diagnosis of biliary disease using POC with a mother-baby system and video cholangioscope (CHF-B260; Olympus), which may increase the detectability of biliary-tract disease, even of minute lesions. However, POC with the mother-baby scope system is cumbersome, which limits its clinical use. Direct POC using an ultra-slim endoscope can be performed by a single endoscopist; it is not only provide superior endoscopic images with a standard endoscopy unit, but NBI can also be performed easily during the endoscope examination.5,6,11,12

Although it was difficult to see an objective difference between the WL and NBI examinations in this case, the NBI examination suggested a malignant stricture rather than a benign one because it showed abnormal superficial mucosal change, with irregularly dilated vessels. Based on this finding, we could target a biopsy of the suspicious lesion precisely.

Our procedure has several limitations. It needs specialized accessories, such as an intraductal balloon, and a skilled endoscopist. In addition, optical magnification for enhancing NBI cannot be used with the existing ultra-slim endoscope and it is time consuming to clear the bile duct because bile on the NBI is recognized as a reddish fluid.1

In conclusion, our case demonstrated the possibility of detecting early bile duct cancer using NBI under direct POC.

Fig. 1.Abdominal computed tomography showing abnormal stricture of the intrahepatic duct.
Fig. 2.Cholangiogram showing stricture of the left hepatic duct with proximal dilatation.
Fig. 3.Fluoroscopy image of the direct peroral cholangioscopy with an ultra-slim endoscope showing the advance of the endoscope into the left intrahepatic duct.
Fig. 4.White light (A) and narrow-band imaging (B) of the stricture in the left hepatic duct.
Fig. 5.Histopathologically, the resected specimen shows focal papillary adenocarcinoma confined to the mucosa (H&E stain, ×20).
  1. Shim, CS, Neuhaus, H, Tamada, K. Direct cholangioscopy. Endoscopy, 2003;35;752-758.
    Pubmed
  2. Fukuda, Y, Tsuyuguchi, T, Sakai, Y, Tsuchiya, S, Saisyo, H. Diagnostic utility of peroral cholangioscopy for various bile-duct lesions. Gastrointest Endosc, 2005;62;374-382.
    Pubmed
  3. Nimura, Y, Shionoya, S, Hayakawa, N, Kamiya, J, Kondo, S, Yasui, A. Value of percutaneous transhepatic cholangioscopy (PTCS). Surg Endosc, 1988;2;213-219.
    Pubmed
  4. Bogardus, ST, Hanan, I, Ruchim, M, Goldberg, MJ. "Mother-baby" biliary endoscopy: the University of Chicago experience. Am J Gastroenterol, 1996;91;105-110.
    Pubmed
  5. Larghi, A, Waxman, I. Endoscopic direct cholangioscopy by using an ultra-slim upper endoscope: a feasibility study. Gastrointest Endosc, 2006;63;853-857.
    Pubmed
  6. Moon, JH, Ko, BM, Choi, HJ, et al. Intraductal balloon-guided direct peroral cholangioscopy with an ultraslim upper endoscope (with videos). Gastrointest Endosc, 2009;70;297-302.
    Pubmed
  7. Machida, H, Sano, Y, Hamamoto, Y, et al. Narrow-band imaging in the diagnosis of colorectal mucosal lesions: a pilot study. Endoscopy, 2004;36;1094-1098.
    Pubmed
  8. Nakayoshi, T, Tajiri, H, Matsuda, K, Kaise, M, Ikegami, M, Sasaki, H. Magnifying endoscopy combined with narrow band imaging system for early gastric cancer: correlation of vascular pattern with histopathology (including video). Endoscopy, 2004;36;1080-1084.
    Pubmed
  9. Kara, MA, Ennahachi, M, Fockens, P, ten Kate, FJ, Bergman, JJ. Detection and classification of the mucosal and vascular patterns (mucosal morphology) in Barrett's esophagus by using narrow band imaging. Gastrointest Endosc, 2006;64;155-166.
    Pubmed
  10. Itoi, T, Sofuni, A, Itokawa, F, et al. Peroral cholangioscopic diagnosis of biliary-tract diseases by using narrow-band imaging (with videos). Gastrointest Endosc, 2007;66;730-736.
    Pubmed
  11. Brauer, BC, Fukami, N, Chen, YK. Direct cholangioscopy with narrow-band imaging, chromoendoscopy, and argon plasma coagulation of intraductal papillary mucinous neoplasm of the bile duct (with videos). Gastrointest Endosc, 2008;67;574-576.
    Pubmed
  12. Choi, HJ, Moon, JH, Ko, BM, et al. Overtube-balloon-assisted direct peroral cholangioscopy by using an ultra-slim upper endoscope (with videos). Gastrointest Endosc, 2009;69;935-940.
    Pubmed

Article

Case Report

Gut Liver 2011; 5(3): 377-379

Published online September 30, 2011 https://doi.org/10.5009/gnl.2011.5.3.377

Copyright © Gut and Liver.

Early Bile Duct Cancer Detected by Direct Peroral Cholangioscopy with Narrow-Band Imaging after Bile Duct Stone Removal

Hyung Ki Kim, Jong Ho Moon*, Hyun Jong Choi, Hee Kyung Kim*, Seul Ki Min, Jong Kyu Park, Young Deok Cho, Sang-Heum Park, and Moon Sung Lee

Digestive Disease Center, Soonchunhyang University School of Medicine, Bucheon, Korea.

*Department of Internal Medicine and Pathology, Soonchunhyang University School of Medicine, Bucheon, Korea.

Correspondence to: Jong Ho Moon. Digestive Disease Center, Soonchunhyang University Bucheon Hospital, Soonchunhyang University School of Medicine, 1174 Jung-dong, Wonmi-gu, Bucheon 420-767, Korea. Tel: +82-32-621-5094, Fax: +82-32-621-5080, jhmoon@schmc.ac.kr

Received: February 26, 2010; Accepted: June 3, 2010

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Cholangioscopy not only enables the direct visualization of the biliary tree, but also allows for forceps biopsy to diagnosis early cholangiocarcinoma. Recently, some reports have suggested the clinical usefulness of direct peroral cholangioscopy (POC) using an ultra-slim endoscope with a standard endoscopic unit by a single operator. Enhanced endoscopy, such as narrow band imaging (NBI), can be helpful for detecting early neoplasia in the gastrointestinal tract and is easily applicable during direct POC. A 63-year-old woman with acute cholangitis had persistent bile duct dilation on the left hepatic duct after common bile duct stone removal and clinical improvement. We performed direct POC with NBI using an ultra-slim upper endoscope to examine the strictured segment. NBI examination showed an irregular surface and polypoid structure with tumor vessels. Target biopsy under direct endoscopic visualization was performed, and adenocarcinoma was documented. The patient underwent an extended left hepatectomy, and the resected specimen showed early bile duct cancer confined to the ductal mucosa.

Keywords: Early bile duct cancer, Direct peroral cholangioscopy, Narrow band imaging

INTRODUCTION

The early diagnosis of cholangiocarcinoma (CC) is important because surgery is the only curative treatment. Cholangioscopy not only enables direct visualization of the biliary tree, but also allows forceps biopsy to diagnosis early CC.1-3 However, the clinical use of percutaneous3 or peroral cholangioscopy using a "mother-baby scope"1,4,5 is limited because of its invasiveness or inconvenience. Recently, some reports have indicated the clinical usefulness of direct peroral cholangioscopy (POC) using an ultra-slim endoscope5,6 with a standard endoscopic unit by a single operator. Enhanced endoscopy, such as narrow band imaging (NBI), can be helpful for detecting early neoplasia in the gastrointestinal tract.7-9 NBI is easily applied during direct POC using an ultra-slim endoscope. We report a case of early bile duct cancer diagnosed at direct POC with NBI using an ultra-slim endoscope.

CASE REPORT

A 63-year-old woman was admitted to the emergency room with right upper quadrant pain with fever over 2 days. Laboratory findings were as follows: white blood cell count 14,400/µL, total/direct bilirubin 2.89/2.09 mg/dL, gamma-glutamyl-transpeptidase 1,470 IU/L, and alkaline phosphatase 1,334 IU/L. Abdominal computed tomography showed bile duct dilation and high density stone on ampullary portion (Fig. 1). After the removal of the impacted stone on the ampullary orifice and nasobiliary drainage, clinical symptoms were improved. On the 3rd hospital day, we performed endoscopic retrograde cholangiography (ERC) to evaluate for remnant stones. ERC showed no remnant stone but duct dilation on left hepatic duct and short segment stricture on the orifice (Fig. 2).

We examined the stricture under endoscopic visualization using intraductal balloon-guided direct POC using an ultra-slim upper endoscope (GIF-XP260N; Olympus, Tokyo, Japan) as our previous report.6 The endoscope was inserted into the ampulla of Vater. After advancing the 5 F balloon catheter (MTW Endoskopie, Wesel, Germany) through the stricture via the guidewire, the balloon was inflated to anchor it inside the left hepatic duct. The endoscope was advanced over the balloon catheter into the proximal bile duct using the ropeway method (Fig. 3). We observed the stricture under white light (WL) and NBI (Evis Lucera 260 System; Olympus) examination.

The WL examination showed ill-defined hyperemia at the stricture site. NBI showed better contrast than did the WL examination, with a well-defined margin and prominent, thickened vascular markings (Fig. 4). We performed a target biopsy of the lesion using biopsy forceps (FB-19K-1; Olympus). Histopathological examination revealed a well-differentiated adenocarcinoma. The patient underwent an extended left hepatectomy. Histopathologically, the resected specimen showed focal papillary adenocarcinoma confined to the ductal mucosa (Fig. 5).

DISCUSSION

Cholangioscopy provides advantages over endoscopic retrograde cholangiopancreatography (ERCP) for the diagnosis of lesions in the bile duct. Visual information from the endoscope disclose characteristics of filling defects or stricture site, which enables us not only to differentiate between benign and malignant strictures, but also to apply treatment or to biopsy in some cases.1 Direct POC with ultra-slim upper endoscope has been proposed as a potential solutions for the direct visual examination of the biliary tree.5 In this case, there were persistent bile duct stricture after stone removal. At present, there are some limitation of the cholangiogram or cytology study including brush cytology to differentiate between benign and malignancy. We evaluated the stricture site by using the direct POC with ultra-slim endocope. It provides white light image of the lesion and NBI, thus enable to target biopsy for proper diagnosis.

The recently introduced NBI is helpful for diagnosing early gastrointestinal neoplasia due to its ability to yield clear images of the surface structure and microvessels.7-9 Although it has not become established in biliary disease, Itoi et al.10 reported the usefulness of NBI for the diagnosis of biliary disease using POC with a mother-baby system and video cholangioscope (CHF-B260; Olympus), which may increase the detectability of biliary-tract disease, even of minute lesions. However, POC with the mother-baby scope system is cumbersome, which limits its clinical use. Direct POC using an ultra-slim endoscope can be performed by a single endoscopist; it is not only provide superior endoscopic images with a standard endoscopy unit, but NBI can also be performed easily during the endoscope examination.5,6,11,12

Although it was difficult to see an objective difference between the WL and NBI examinations in this case, the NBI examination suggested a malignant stricture rather than a benign one because it showed abnormal superficial mucosal change, with irregularly dilated vessels. Based on this finding, we could target a biopsy of the suspicious lesion precisely.

Our procedure has several limitations. It needs specialized accessories, such as an intraductal balloon, and a skilled endoscopist. In addition, optical magnification for enhancing NBI cannot be used with the existing ultra-slim endoscope and it is time consuming to clear the bile duct because bile on the NBI is recognized as a reddish fluid.1

In conclusion, our case demonstrated the possibility of detecting early bile duct cancer using NBI under direct POC.

Fig 1.

Figure 1.Abdominal computed tomography showing abnormal stricture of the intrahepatic duct.
Gut and Liver 2011; 5: 377-379https://doi.org/10.5009/gnl.2011.5.3.377

Fig 2.

Figure 2.Cholangiogram showing stricture of the left hepatic duct with proximal dilatation.
Gut and Liver 2011; 5: 377-379https://doi.org/10.5009/gnl.2011.5.3.377

Fig 3.

Figure 3.Fluoroscopy image of the direct peroral cholangioscopy with an ultra-slim endoscope showing the advance of the endoscope into the left intrahepatic duct.
Gut and Liver 2011; 5: 377-379https://doi.org/10.5009/gnl.2011.5.3.377

Fig 4.

Figure 4.White light (A) and narrow-band imaging (B) of the stricture in the left hepatic duct.
Gut and Liver 2011; 5: 377-379https://doi.org/10.5009/gnl.2011.5.3.377

Fig 5.

Figure 5.Histopathologically, the resected specimen shows focal papillary adenocarcinoma confined to the mucosa (H&E stain, ×20).
Gut and Liver 2011; 5: 377-379https://doi.org/10.5009/gnl.2011.5.3.377

References

  1. Shim, CS, Neuhaus, H, Tamada, K. Direct cholangioscopy. Endoscopy, 2003;35;752-758.
    Pubmed
  2. Fukuda, Y, Tsuyuguchi, T, Sakai, Y, Tsuchiya, S, Saisyo, H. Diagnostic utility of peroral cholangioscopy for various bile-duct lesions. Gastrointest Endosc, 2005;62;374-382.
    Pubmed
  3. Nimura, Y, Shionoya, S, Hayakawa, N, Kamiya, J, Kondo, S, Yasui, A. Value of percutaneous transhepatic cholangioscopy (PTCS). Surg Endosc, 1988;2;213-219.
    Pubmed
  4. Bogardus, ST, Hanan, I, Ruchim, M, Goldberg, MJ. "Mother-baby" biliary endoscopy: the University of Chicago experience. Am J Gastroenterol, 1996;91;105-110.
    Pubmed
  5. Larghi, A, Waxman, I. Endoscopic direct cholangioscopy by using an ultra-slim upper endoscope: a feasibility study. Gastrointest Endosc, 2006;63;853-857.
    Pubmed
  6. Moon, JH, Ko, BM, Choi, HJ, et al. Intraductal balloon-guided direct peroral cholangioscopy with an ultraslim upper endoscope (with videos). Gastrointest Endosc, 2009;70;297-302.
    Pubmed
  7. Machida, H, Sano, Y, Hamamoto, Y, et al. Narrow-band imaging in the diagnosis of colorectal mucosal lesions: a pilot study. Endoscopy, 2004;36;1094-1098.
    Pubmed
  8. Nakayoshi, T, Tajiri, H, Matsuda, K, Kaise, M, Ikegami, M, Sasaki, H. Magnifying endoscopy combined with narrow band imaging system for early gastric cancer: correlation of vascular pattern with histopathology (including video). Endoscopy, 2004;36;1080-1084.
    Pubmed
  9. Kara, MA, Ennahachi, M, Fockens, P, ten Kate, FJ, Bergman, JJ. Detection and classification of the mucosal and vascular patterns (mucosal morphology) in Barrett's esophagus by using narrow band imaging. Gastrointest Endosc, 2006;64;155-166.
    Pubmed
  10. Itoi, T, Sofuni, A, Itokawa, F, et al. Peroral cholangioscopic diagnosis of biliary-tract diseases by using narrow-band imaging (with videos). Gastrointest Endosc, 2007;66;730-736.
    Pubmed
  11. Brauer, BC, Fukami, N, Chen, YK. Direct cholangioscopy with narrow-band imaging, chromoendoscopy, and argon plasma coagulation of intraductal papillary mucinous neoplasm of the bile duct (with videos). Gastrointest Endosc, 2008;67;574-576.
    Pubmed
  12. Choi, HJ, Moon, JH, Ko, BM, et al. Overtube-balloon-assisted direct peroral cholangioscopy by using an ultra-slim upper endoscope (with videos). Gastrointest Endosc, 2009;69;935-940.
    Pubmed
Gut and Liver

Vol.18 No.3
May, 2024

pISSN 1976-2283
eISSN 2005-1212

qrcode
qrcode

Share this article on :

  • line

Popular Keywords

Gut and LiverQR code Download
qr-code

Editorial Office