More results...

Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Filter by Categories
Abdominal Radiology, Original Research
Abdominal Radiology, Pictorial Essay
Anthropology and Dental Radiology, Original Research
Breast Imaging, Case Report
Breast Imaging, Original Research
Breast Imaging, Pictorial Essay
Breast Imaging, Review Article
Cardiopulmonary Imaging, Case Report
Cardiopulmonary Imaging, Case Series
Cardiopulmonary Imaging, Education
Cardiopulmonary Imaging, Original Research
Cardiopulmonary Imaging, Pictorial Essay
Cardiopulmonary Imaging, Review Article
Case Report
Case Report, Breast Imaging
Case Report, Cardiopulmonary Imaging
Case Report, Diagnostic Radiology
Case Report, Neuroradiology/Head and Neck Imaging
Case Report, Vascular and Interventional Radiology
Case Series
Case Series, Diagnostic Radiology
Case Series, Vascular and Interventional Radiology
DENTAL ARTICLE
Dental Radiology, Case Report
Dental Radiology, Case Series
Dental Radiology, Original Research
Diagnostic Radiology, Case Report
Diagnostic Radiology, Case Series
Diagnostic Radiology, Original Research
Diagnostic Radiology, Pictorial Essay
Diagnostic Radiology, Review Article
Editorial
Education, Original Research
Emergency, Original Research
Erratum
Gastrointestinal Imaging, Case Report
Gastrointestinal Imaging, Case Series
Gastrointestinal Imaging, Original Research
Gastrointestinal Imaging, Pictorial Essay
General and Emergency Radiology, Original Research
General and Emergency Radiology, Review Article
Genitourinary and Gynecologic Imaging, Case Report
Genitourinary and Gynecologic Imaging, Original Research
Imaging Science, Original Research
Interventional Radiology, Original Research
Letter to Editor
Musculoskeletal Imaging, Case Report
Musculoskeletal Imaging, Original Article
Musculoskeletal Imaging, Original Research
Musculoskeletal Imaging, Pictorial Essay
Musculoskeletal Imaging, Review Article
Neuroradiology , Review Article
Neuroradiology Head and Neck Imaging, Pictorial Essay
Neuroradiology, Case Report
Neuroradiology, Pictorial Essay
Neuroradiology/Head and Neck Imaging, Case Report
Neuroradiology/Head and Neck Imaging, Case Series
Neuroradiology/Head and Neck Imaging, Original Research
Neuroradiology/Head and Neck Imaging, Review Article
Neuroradiology/Spine Imaging, Original Research
Nuclear Medicine, Case Report
Nuclear Medicine, Original Research
Nuclear Medicine, Pictorial Essay
Original Article
Original Article, Neuroradiology
Original Research
Original Research Article
Original Research, Dental Radiology
Original Research, Descriptive Study
Original Research, Diagnostic Radiology
Original Research, Gastrointestinal Imaging
Original Research, Genitourinary and Gynecologic Imaging
Original Research, Musculoskeletal Imaging
Original Research, Neuroradiology/Head and Neck Imaging
Original Research, Nuclear Medicine
Original Research, Vascular and Interventional Radiology
Pediatric Imaging, Case Report
Pediatric Imaging, Pictorial Essay
PICTORIAL ESSAY
PICTORIAL REVIEW
Radiologic-Pathologic Correlation
RADIOLOGICAL-PATHOLOGICAL CORRELATION
Radiology Business, Original Research
Research Article
Review Article
Review Article, Diagnostic Radiology
Review Article, Gastrointestinal imaging
Review Article, Musculoskeletal
Review Article, Vascular and Interventional Radiology
Technical Innovation
Technical Innovation, Gastrointestinal Imaging
Ultrasound, Case Report
Ultrasound, Original Research
Ultrasound, Review Article
Vascular and International Radiology, Case Report
Vascular and Interventional Radiology, Case Report
Vascular and Interventional Radiology, Case Series
Vascular and Interventional Radiology, Original Research
Vascular and Interventional Radiology, Pictorial Essay
Vascular and Interventional Radiology, Review Article
Vascular and Interventional Radiology, Short Communication
Vascular and Interventional, Original Research

More results...

Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Filter by Categories
Abdominal Radiology, Original Research
Abdominal Radiology, Pictorial Essay
Anthropology and Dental Radiology, Original Research
Breast Imaging, Case Report
Breast Imaging, Original Research
Breast Imaging, Pictorial Essay
Breast Imaging, Review Article
Cardiopulmonary Imaging, Case Report
Cardiopulmonary Imaging, Case Series
Cardiopulmonary Imaging, Education
Cardiopulmonary Imaging, Original Research
Cardiopulmonary Imaging, Pictorial Essay
Cardiopulmonary Imaging, Review Article
Case Report
Case Report, Breast Imaging
Case Report, Cardiopulmonary Imaging
Case Report, Diagnostic Radiology
Case Report, Neuroradiology/Head and Neck Imaging
Case Report, Vascular and Interventional Radiology
Case Series
Case Series, Diagnostic Radiology
Case Series, Vascular and Interventional Radiology
DENTAL ARTICLE
Dental Radiology, Case Report
Dental Radiology, Case Series
Dental Radiology, Original Research
Diagnostic Radiology, Case Report
Diagnostic Radiology, Case Series
Diagnostic Radiology, Original Research
Diagnostic Radiology, Pictorial Essay
Diagnostic Radiology, Review Article
Editorial
Education, Original Research
Emergency, Original Research
Erratum
Gastrointestinal Imaging, Case Report
Gastrointestinal Imaging, Case Series
Gastrointestinal Imaging, Original Research
Gastrointestinal Imaging, Pictorial Essay
General and Emergency Radiology, Original Research
General and Emergency Radiology, Review Article
Genitourinary and Gynecologic Imaging, Case Report
Genitourinary and Gynecologic Imaging, Original Research
Imaging Science, Original Research
Interventional Radiology, Original Research
Letter to Editor
Musculoskeletal Imaging, Case Report
Musculoskeletal Imaging, Original Article
Musculoskeletal Imaging, Original Research
Musculoskeletal Imaging, Pictorial Essay
Musculoskeletal Imaging, Review Article
Neuroradiology , Review Article
Neuroradiology Head and Neck Imaging, Pictorial Essay
Neuroradiology, Case Report
Neuroradiology, Pictorial Essay
Neuroradiology/Head and Neck Imaging, Case Report
Neuroradiology/Head and Neck Imaging, Case Series
Neuroradiology/Head and Neck Imaging, Original Research
Neuroradiology/Head and Neck Imaging, Review Article
Neuroradiology/Spine Imaging, Original Research
Nuclear Medicine, Case Report
Nuclear Medicine, Original Research
Nuclear Medicine, Pictorial Essay
Original Article
Original Article, Neuroradiology
Original Research
Original Research Article
Original Research, Dental Radiology
Original Research, Descriptive Study
Original Research, Diagnostic Radiology
Original Research, Gastrointestinal Imaging
Original Research, Genitourinary and Gynecologic Imaging
Original Research, Musculoskeletal Imaging
Original Research, Neuroradiology/Head and Neck Imaging
Original Research, Nuclear Medicine
Original Research, Vascular and Interventional Radiology
Pediatric Imaging, Case Report
Pediatric Imaging, Pictorial Essay
PICTORIAL ESSAY
PICTORIAL REVIEW
Radiologic-Pathologic Correlation
RADIOLOGICAL-PATHOLOGICAL CORRELATION
Radiology Business, Original Research
Research Article
Review Article
Review Article, Diagnostic Radiology
Review Article, Gastrointestinal imaging
Review Article, Musculoskeletal
Review Article, Vascular and Interventional Radiology
Technical Innovation
Technical Innovation, Gastrointestinal Imaging
Ultrasound, Case Report
Ultrasound, Original Research
Ultrasound, Review Article
Vascular and International Radiology, Case Report
Vascular and Interventional Radiology, Case Report
Vascular and Interventional Radiology, Case Series
Vascular and Interventional Radiology, Original Research
Vascular and Interventional Radiology, Pictorial Essay
Vascular and Interventional Radiology, Review Article
Vascular and Interventional Radiology, Short Communication
Vascular and Interventional, Original Research

More results...

Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Filter by Categories
Abdominal Radiology, Original Research
Abdominal Radiology, Pictorial Essay
Anthropology and Dental Radiology, Original Research
Breast Imaging, Case Report
Breast Imaging, Original Research
Breast Imaging, Pictorial Essay
Breast Imaging, Review Article
Cardiopulmonary Imaging, Case Report
Cardiopulmonary Imaging, Case Series
Cardiopulmonary Imaging, Education
Cardiopulmonary Imaging, Original Research
Cardiopulmonary Imaging, Pictorial Essay
Cardiopulmonary Imaging, Review Article
Case Report
Case Report, Breast Imaging
Case Report, Cardiopulmonary Imaging
Case Report, Diagnostic Radiology
Case Report, Neuroradiology/Head and Neck Imaging
Case Report, Vascular and Interventional Radiology
Case Series
Case Series, Diagnostic Radiology
Case Series, Vascular and Interventional Radiology
DENTAL ARTICLE
Dental Radiology, Case Report
Dental Radiology, Case Series
Dental Radiology, Original Research
Diagnostic Radiology, Case Report
Diagnostic Radiology, Case Series
Diagnostic Radiology, Original Research
Diagnostic Radiology, Pictorial Essay
Diagnostic Radiology, Review Article
Editorial
Education, Original Research
Emergency, Original Research
Erratum
Gastrointestinal Imaging, Case Report
Gastrointestinal Imaging, Case Series
Gastrointestinal Imaging, Original Research
Gastrointestinal Imaging, Pictorial Essay
General and Emergency Radiology, Original Research
General and Emergency Radiology, Review Article
Genitourinary and Gynecologic Imaging, Case Report
Genitourinary and Gynecologic Imaging, Original Research
Imaging Science, Original Research
Interventional Radiology, Original Research
Letter to Editor
Musculoskeletal Imaging, Case Report
Musculoskeletal Imaging, Original Article
Musculoskeletal Imaging, Original Research
Musculoskeletal Imaging, Pictorial Essay
Musculoskeletal Imaging, Review Article
Neuroradiology , Review Article
Neuroradiology Head and Neck Imaging, Pictorial Essay
Neuroradiology, Case Report
Neuroradiology, Pictorial Essay
Neuroradiology/Head and Neck Imaging, Case Report
Neuroradiology/Head and Neck Imaging, Case Series
Neuroradiology/Head and Neck Imaging, Original Research
Neuroradiology/Head and Neck Imaging, Review Article
Neuroradiology/Spine Imaging, Original Research
Nuclear Medicine, Case Report
Nuclear Medicine, Original Research
Nuclear Medicine, Pictorial Essay
Original Article
Original Article, Neuroradiology
Original Research
Original Research Article
Original Research, Dental Radiology
Original Research, Descriptive Study
Original Research, Diagnostic Radiology
Original Research, Gastrointestinal Imaging
Original Research, Genitourinary and Gynecologic Imaging
Original Research, Musculoskeletal Imaging
Original Research, Neuroradiology/Head and Neck Imaging
Original Research, Nuclear Medicine
Original Research, Vascular and Interventional Radiology
Pediatric Imaging, Case Report
Pediatric Imaging, Pictorial Essay
PICTORIAL ESSAY
PICTORIAL REVIEW
Radiologic-Pathologic Correlation
RADIOLOGICAL-PATHOLOGICAL CORRELATION
Radiology Business, Original Research
Research Article
Review Article
Review Article, Diagnostic Radiology
Review Article, Gastrointestinal imaging
Review Article, Musculoskeletal
Review Article, Vascular and Interventional Radiology
Technical Innovation
Technical Innovation, Gastrointestinal Imaging
Ultrasound, Case Report
Ultrasound, Original Research
Ultrasound, Review Article
Vascular and International Radiology, Case Report
Vascular and Interventional Radiology, Case Report
Vascular and Interventional Radiology, Case Series
Vascular and Interventional Radiology, Original Research
Vascular and Interventional Radiology, Pictorial Essay
Vascular and Interventional Radiology, Review Article
Vascular and Interventional Radiology, Short Communication
Vascular and Interventional, Original Research
View/Download PDF

Translate this page into:

Gastrointestinal Imaging
Case Report
2021
:11;
32
doi:
10.25259/JCIS_57_2021

Choledocho-nodal Fistula: Uncommon Cause of Obstructive Jaundice in a Patient with HCC Diagnosed by Combined ERCP/EUS

Department of Hepatology, Gastroenetrology and Infectious Diseases, Kafrelshiekh University, Kafr Elshikh, Egypt
Department of Diagnostic and Interventional Radiology, Faculty of Medicine, Kafrelshiekh University, Kafr Elshikh, Egypt
Corresponding author: Mohamed H. Emara, Departments of Hepatology, Gastroenetrology and Infectious Diseases, Kafrelshiekh University, 33516, Kafr Elshikh, Egypt. emara_20007@yahoo.com
Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Emara MH, Zaghloul MS, Mahros AM, Emara EH. Choledocho-nodal fistula: Uncommon cause of obstructive jaundice in a patient with HCC diagnosed by combined ERCP/EUS. J Clin Imaging Sci 2021;11:32.

Abstract

A 58-year-old male patient presented with advanced hepatocellular carcinoma underwent transarterial chemoembolization (TACE) for hepatic focal lesions followed by TACE for a solitary hilar nodal metastasis combined with regorafenib therapy. One month later, the patient developed progressive jaundice. Work-up showed obstructive jaundice with intrahepatic biliary radicles dilatation. The diagnosis and treatment was achieved by combining endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography and showed uncommon cause of obstructive jaundice due to common bile duct compression by a choledocho-nodal fistula following TACE of a metastatic hilar lymph node.

Keywords

Choledochal
Hepatocellular carcinoma
Obstructive jaundice
Transarterial chemoembolization

INTRODUCTION

Obstructive jaundice results from obstruction of the biliary system starting from inside the liver tissue to the duodenal papilla. Causes include luminal obstruction, for example, by stone or cancer, stricture of the wall as in malignancies, and sclerosing cholangitis or compression from outside as in case of malignant lymph nodes (LN) and cancer pancreas.[1]

In cases of hepatocellular carcinoma (HCC), the development of jaundice may be related to; infiltration of the bile ducts, obstruction of the lumen by dislodged tumor tissues, or compression of bile ducts by metastatic LNs. Furthermore, with progression of HCC and exhaustion of the functioning liver tissue, the jaundice becomes deeper.[1]

In the current case report, we reported uncommon case that developed obstructive jaundice after performing transarterial chemoembolization (TACE) for a solitary hilar metastatic LN. To the best of our knowledge, this is the 1st time to describe choledocho-nodal fistula as a cause of obstructive jaundice.

CASE REPORT

Here, we present a 58-year-old male patient with multifocal HCC. The patient was treated 3 times with TACE with the last session for a solitary hilar LN that appeared after the first session of TACE, and afterward, he was kept by his oncologist on regorafenib 40 mg tid. One month before admission, he developed progressive jaundice and was admitted to the hospital for evaluation. On admission, his laboratories showed high serum bilirubin: Total bilirubin 44.4 mg/dl, direct bilirubin 29.9 mg/dl, ALT 49 IU/l, AST 98 IU/l, and serum albumin 3.6 mg/dl while AFP was 12,000 ng/ml. The baseline laboratories and imaging modalities for the patient were lacking because the patient had a follow up file in another center and presented and presented to us with the jaundice episode.

Abdominal US showed dilated common bile duct (CBD), and non-calculous gallbladder distension and a complementary magnetic resonance cholangiopancreatography (MRCP) showed diffusely dilated upper CBD with compression to the mid-lower segment by a cystic lesion probably from the pancreas. Endoscopic retrograde cholangiopancreatography (ERCP) was done, and on filling downstream, the dye besides showing dilated upper CBD and intrahepatic biliary radicles began to collect in a rounded fashion around the strictured middle-lower CBD [Figure 1].

Figure 1:
A 58-year-old male patient presented with obstructive jaundice due to choledocho-nodal fistula. Endoscopic retrograde cholangiopancreatography with cholangiogram showing dilated upper common bile duct (CBD) and intrahepatic biliary radicles (short arrow) and a rounded lesion compressing the lower CBD (long arrow) consistent with the necrotic lymph node.

This was not possibly a biliary leak due localized nature of the lesion and a possibility of choledochal cyst was proposed. A plastic stent 12 cm/10 F was inserted with good biliary drainage. However, the dye retained in the lesion.

An upper GIT endoscopy was done after ERCP withdrawal and showed 1st part duodenal ulcer overlying a bulbar swelling suggesting compression. A decision for an endoscopic ultrasonography (EUS) was taken at the same session. EUS showed partially cystic lesion with heterogeneous content around the CBD and surrounding the inserted plastic stent [Figure 2].

Figure 2:
A 58-year-old male patient presented with obstructive jaundice due to choledocho-nodal fistula. Endoscopic ultrasonography image showing partially cystic lesion (long arrow) with heterogeneous content around the common bile duct consistent with the necrotic lymph node, surrounding the inserted plastic stent (short arrow).

Aspiration of the fluid content of that lesion revealed bile [that was confirmed also in laboratory analysis, Figure 3]. Fluoroscopy confirmed the reduced lesion size after EUS aspiration [Figure 4].

Figure 3:
A 58-year-old male patient presented with obstructive jaundice due to choledocho-nodal fistula. Endoscopic ultrasonography with aspiration from the necrotic lymph node showing the yellow fluid consistent with bile. The bile source was confirmed on laboratory examination.
Figure 4:
A 58-year-old male patient presented with obstructive jaundice due to choledocho-nodal fistula. Fluoroscopy/ cholangiogram showing endoscopic ultrasonography needle aspirating the lesion with obvious size reduction (long arrow) in comparison to the size in Figure 1. Note the stent passing through the lesion (short arrow).

Follow-up of the patient after stent insertion by bilirubin level showed reduction of the serum total and direct bilirubin to 14.3/10.1 mg/dl after 1 week and to 6.4/4.7 mg after 2 weeks, respectively.

The patient was scheduled for follow-up after 3 months for imaging (CT and MRCP), ERCP for removal of the plastic stent, reevaluation, and arrangement for SEMS if needed. Unfortunately, the patient passed out 7 weeks after hospital discharge due to unrelated event.

DISCUSSION

In patients with advanced HCC and Barcelona Clinic Liver Cancer Stage B (multinodular disease), like our patient, palliative TACE is recommended by the current guidelines.[2] The situation of our patient is quite different because it seems that he developed a single large hilar LN and that probably what encouraged the interventional radiologist to plan for nodal ablation with TACE [Figure 5]. Later, the oncologist added the regorafenib, an oral multikinase inhibitor.

Figure 5:
A 58-year-old male patient presented with obstructive jaundice due to choledocho-nodal fistula. CT scan image showing intense lipidol trapping in both the hepatic focal lesion and the lymph node.

Our patient was admitted due to progressive jaundice following nodal injection/regorafenib therapy. and initially, we sought in hepatic decompensation due to regorafenib. After full laboratories and imaging that revealed dilated biliary system, an ERCP was planned. During the procedure, a suspicion on choledochal cyst was rapidly excluded when the dye failed to be drained after limited sphincterotomy stent insertion and this further confirmed when we shifted to EUS which showed a partially cystic lesion with heterogeneous content and the plastic stent was seen within the lesion which is consistent with the injected LN. It is possible that the LN after injection developed necrosis which penetrated and communicated with the CBD. The bile leak inside the necrotic LN made it sizeable enough to compress the CBD and manifest as obstructive jaundice. One other possibility that cannot be ignored is the technical pitfall during TACE. It is also possible that CBD was punctured iatrogenically and communicated with the LN during injection process with the final result of bile leak within. Injuries following TACE procedures particularly biliary injuries are infrequently reported in the literature. Injuries following TACE seem to be related to microcatheter use.[3]

Uncommon causes of obstructive jaundice have been reported in the literature and range from Mirizzi syndrome, intraductal metastases from distant tumors, outside compression by an aberrant hepatic artery, uncommon tumors, and biliary parasites.[4,5] However, to the best of our knowledge, this is the first case of fistulizing necrotic LN communicating and compressing the CBD to be described in the literature.

The case presented here is important from different aspects. First, the clinical point of view. We are not sure that injection of a malignant metastatic LN would favor better outcome in a patient with advanced HCC. In fact, this behavior should be weighted from the risk point of view in comparison to the expected benefits. There is some evidence in the literature that showed survival benefit for combined TACE for both liver lesions and its regional nodal metastases[6] although not supported by any current guidelines. We believe that this patient with advanced HCC was not an ideal candidate for nodal TACE.

Second, the endoscopic technical point of view. It seems that ERCP/EUS use is superior in evaluating CBD pathology than ERCP alone and although this was reported in the literature,[7] it is reemphasized by this case. With ERCP alone, we thought in a biliary leak and choledochal cyst and also good biliary drainage was achieved with insertion of a plastic stent yet with the introduction of EUS, we precisely identified the nature of the lesion and we aspirated its bile content.

Development of ERCP decades back was an era in the management of pancreaticobiliary disorders because it reduced the morbidity, mortality, and cost of surgical interventions.[8] However, the introduction of EUS was a paradigm shift in management of pancreatic disorders.[9] Furthermore, EUS introduction in management of biliary disorders is growing and its use may be adjuvant or a rescue in ERCP failed cases.[10] In our case presented here, EUS completed the hidden part in the diagnosis of this case and we believe that if our unit was not armed with the EUS, we probably missed the diagnosis.

CONCLUSION

This is uncommon case of obstructive jaundice due to CBD compression by a choledocho-nodal fistula following injection of a metastatic hilar LN in a patient with HCC. The diagnosis was achieved by combining ERCP and EUS.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

  1. , . Pathophysiological consequences of obstructive jaundice and perioperative management. Hepatobiliary Pancreat Dis Int. 2018;17:17-21.
    [CrossRef] [PubMed] [Google Scholar]
  2. , , , , , , et al. Hepatocellular carcinoma: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2018;29(Suppl 4):iv238-55.
    [CrossRef] [PubMed] [Google Scholar]
  3. , , , , . Bile duct injury after transcatheter arterial chemoembolization: Risk factors and clinical implications. Hepatogastroenterology. 2014;61:947-53.
    [Google Scholar]
  4. , , , . An uncommon cause of obstructive jaundice: An infrequent neoplasm. Am J Med. 2017;130:e43-5.
    [CrossRef] [PubMed] [Google Scholar]
  5. , , , , , , et al. Detection of parasites during upper gastrointestinal endoscopic procedures. Afro-Egypt J Infect Endem Dis. 2012;2:62-8.
    [CrossRef] [Google Scholar]
  6. , , , , , . Transcatheter arterial chemoembolization (TACE) for lymph node metastases in patients with hepatocellular carcinoma. J Surg Oncol. 2015;112:372-6.
    [CrossRef] [PubMed] [Google Scholar]
  7. , , , , , , et al. Endoscopic ultrasonography in tandem with endoscopic retrograde cholangiopancreatography in the management of suspected distal obstructive jaundice. Eur J Gastroenterol Hepatol. 2013;25:455-9.
    [CrossRef] [PubMed] [Google Scholar]
  8. , . The future of endoscopic retrograde cholangiopancreatography. Gastroenterology. 2017;153:338-44.
    [CrossRef] [PubMed] [Google Scholar]
  9. , . Endoscopic ultrasonography: From the origins to routine EUS. Dig Dis Sci. 2016;61:342-53.
    [CrossRef] [PubMed] [Google Scholar]
  10. , , , , , , et al. Endoscopic ultrasound-guided rendezvous technique after failed endoscopic retrograde cholangiopancreatography: Which approach route is the best? Intern Med. 2017;56:3135-43.
    [CrossRef] [PubMed] [Google Scholar]
Show Sections