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IMAGE IN EUS
Year : 2015  |  Volume : 4  |  Issue : 1  |  Page : 76-77

Paracholedochal varices causing biliopathy in a case of portal vein thrombosis


Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, Haryana, India

Date of Submission17-Feb-2014
Date of Acceptance18-Mar-2014
Date of Web Publication13-Feb-2015

Correspondence Address:
Rajesh Puri
Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, Haryana 122001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2303-9027.151372

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How to cite this article:
Choudhary NS, Puri R, Sud R. Paracholedochal varices causing biliopathy in a case of portal vein thrombosis. Endosc Ultrasound 2015;4:76-7

How to cite this URL:
Choudhary NS, Puri R, Sud R. Paracholedochal varices causing biliopathy in a case of portal vein thrombosis. Endosc Ultrasound [serial online] 2015 [cited 2019 Sep 22];4:76-7. Available from: http://www.eusjournal.com/text.asp?2015/4/1/76/151372

A 35-year-old male was presented with a history of recurrent acute pancreatitis. An abdominal ultrasound showed extrahepatic portal vein thrombosis, normal biliary system and dilated pancreatic duct. Endoscopic ultrasound (EUS) was done to look for biliary system microliths and chronic pancreatitis. It showed features consistent with chronic pancreatitis, portal vein thrombosis and multiple paracholedochal collaterals causing tortuous and irregular common bile duct (CBD) as shown in [Figure 1] and [Figure 2], consistent with portal hypertensive biliopathy. His liver function tests were normal. Regular follow-up was advised to the patient.
Figure 1. Radial endoscopic ultrasound image showing multiple collaterals causing compression of common bile duct, portal vein is not visualized

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Figure 2. Linear endoscopic ultrasound image showing multiple collaterals causing compression of common bile duct

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  Discussion Top


Biliary ductal abnormalities secondary to extrahepatic portal venous obstruction (EHPVO) occurs in 80-100% of patients, these changes are less common in patients with other causes of portal hypertension (cirrhosis 0-33%, idiopathic portal hypertension 9-40%). Higher prevalence of portal hypertensive biliopathy in EHPVO is probably related to long standing portal hypertension in these patients. Symptomatic portal biliopathy (CBD stone leading to cholangitis or stricture leading to cholestasis) is seen in <10% of affected patients. [1] Differential diagnosis of portal hypertensive biliopathy related strictures include primary and secondary sclerosing cholangitis, gallstone disease, ischemic cholangiopathy, AIDS cholangiopathy, autoimmune or recurrent pancreatitis, eosinophilic cholangitis, mast cell cholangiopathy, recurrent pyogenic cholangitis, surgical or blunt trauma and parasitic diseases. [2] The pathogenesis of portal hypertension related strictures include compression by collaterals, mural changes and ischemia (caused by venous supply damage secondary to portal vein thrombosis). The venous drainage of CBD is by veins that ascend along its course, these veins form two plexuses, epicholedochal (on CBD wall) and paracholedochal (parallel to CBD) venous plexus. High venous pressure secondary to portal vein obstruction can be transmitted to these plexuses, and it causes irregular mural changes in the CBD, direct compression by enlarging collaterals and ischemic changes due to portal vein block. [1],[3] Based on magnetic resonance cholangiopancreatography findings, there may be varicoid (smooth indentations by paracholedochal collaterals), fibrotic (stricture) or mixed changes. [3] Asymptomatic patients do not need any treatment if the liver function tests are normal. Management strategies for symptomatic patients include endoscopic stone removal, stenting (if cholangitis secondary to stricture is present) or shunt surgery, [1] generally shunt surgery improves the obstruction, but sometimes bilioenteric anastomosis may be needed. [4] Caution is needed during endoscopic retrograde cholangiopancreatography (ERCP) as there are chances of bleeding from intracholedochal varices and periampullary veins during endoscopic sphincterotomy. [1],[5] Collaterals within CBD appear as filling defects during ERCP and they may bleed from basket manipulation, hence balloon use may be safe (filling defect will not move if it is a varix). [1] EUS may play a great role in minimizing risk of bleeding during ERCP in these patients as periampullary or intracholedochal collaterals can be identified and true stones can be picked up. We feel that EUS should be recommended in these patients (based on availability and cost) before ERCP.

 
  References Top

1.
Dhiman RK, Behera A, Chawla YK, et al. Portal hypertensive biliopathy. Gut 2007;56:1001-8.  Back to cited text no. 1
    
2.
Abdalian R, Heathcote EJ. Sclerosing cholangitis: A focus on secondary causes. Hepatology 2006;44:1063-74.  Back to cited text no. 2
    
3.
Khan MR, Tariq J, Raza R, et al. Portal hypertensive biliopathy: Review of pathophysiology and management. Trop Gastroenterol 2012;33:173-8.  Back to cited text no. 3
    
4.
Chaudhary A, Dhar P, Sarin SK, et al. Bile duct obstruction due to portal biliopathy in extrahepatic portal hypertension: Surgical management. Br J Surg 1998;85:326-9.  Back to cited text no. 4
    
5.
Sharma M, Pathak A. Perforators of common bile duct wall in portal hypertensive biliopathy (with videos). Gastrointest Endosc 2009;70:1041-3.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]


This article has been cited by
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[Pubmed] | [DOI]



 

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