Accepted Manuscript Biliary obstruction from Paraesophageal hernia Rohan Mandaliya, M.B.B.S Deepa Amberker, M.B.B.S John Breckenridge, MD
PII: DOI: Reference:
S1542-3565(14)00630-2 10.1016/j.cgh.2014.04.024 YJCGH 53801
To appear in: Clinical Gastroenterology and Hepatology Accepted Date: 21 April 2014 Please cite this article as: Mandaliya R, Amberker D, Breckenridge J, Biliary obstruction from Paraesophageal hernia, Clinical Gastroenterology and Hepatology (2014), doi: 10.1016/ j.cgh.2014.04.024. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. All studies published in Clinical Gastroenterology and Hepatology are embargoed until 3PM ET of the day they are published as corrected proofs on-line. Studies cannot be publicized as accepted manuscripts or uncorrected proofs.
ACCEPTED MANUSCRIPT
Authors: Rohan Mandaliya, M.B.B.S,
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Department of Medicine, Abington Memorial Hospital, 1200 Old York Road,
SC
PA 19001, USA.
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Email: [email protected] Phone: 215 588 5949
Deepa Amberker,
Department of Medicine, Abington Memorial Hospital, 1200 Old York Road,
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PA 19001,
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M.B.B.S,
USA.
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Email: [email protected] Phone: 215 866 6841
John Breckenridge, MD, Chief,
Department of Radiology,
ACCEPTED MANUSCRIPT
Abington Memorial Hospital, 1200 Old York Road, PA 19001,
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USA. [email protected]
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Corresponding author: Rohan Mandaliya,
M AN U
M.B.B.S, Department of Medicine, Abington Memorial Hospital, 1200 Old York Road,
USA. Email: [email protected]
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Phone: 215 588 5949
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PA 19001,
Funding sources:
Abington Memorial Hospital.
Conflicts of interest: None.
ACCEPTED MANUSCRIPT
Title: Biliary obstruction from Paraesophageal hernia.
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Case:
An 83 year old female presented with three weeks of painless jaundice. She reported to have
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some dyspnea after meals for the past three months. On examination, bowels sounds were audible at the lower half of chest. Abdominal examination was unremarkable. Significant
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laboratory findings included: Aspartate aminotransferase: 200 U/L, alanine aminotransferase: 150 U/L, alkaline phosphatase: 660 U/L and serum total bilirubin: 20 mg/dl. Chest radiography revealed loops of intestine in thoracic cavity; enterothorax (Panel A). Computed Tomography of the chest and abdomen revealed massive hiatal hernia with protrusion
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of stomach, small intestine, colon, pancreas and a portion of common bile duct into thoracic cavity (Panel B). Gall bladder was massively distended with severe intra and extra hepatic biliary dilatation. (Panel B, red arrow). A partial volvulus of common bile duct was present with the
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duct being twisted and running cephalad with acute tapering at the hiatus; thus causing obstructive jaundice (Panel B, green arrow). Panel C (red arrows) shows diaphragm on both the
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sides with massive hiatal hernia. A percutaneous transhepatic cholangiography was performed for biliary decompression. Panel D shows cholangiogram with a biliary catheter in place. It shows common bile duct running superiorly with an abrupt narrowing at the level of hiatus on comparing with the CT scan image and finally ending into duodenum (Panel D, arrow). In Panel D, R represents Right hepatic duct, L: Left hepatic duct, C: Common bile duct, S; stomach, and D: duodenum.
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Laprotomy confirmed type IV paraesophageal hernia. 50 cm of small bowel was resected due to signs of strangulation. Hernia sac was removed and the contents were reduced into abdominal cavity. The crura were sutured with a mesh and a Nissen fundoplication was performed. Repeat
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imaging did not show any narrowing of common bile duct. Jaundice improved immediately post operatively.
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Jaundice due to biliary obstruction is an extremely rare presentation of paraesophageal hiatal hernia. It was first reported in 1986. 1 However only two cases have been reported thereafter. 2,
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3. Massive paraesophageal hernia involving intestine may eventually lead to an abnormal cephalad course of common bile duct through diaphragmatic hiatus and may result into extrinsic compression of the bile duct. Percutaneous cholangiography is important to confirm anatomic position of the bile duct as well as for biliary decompression to prevent cholangitis. Evidence of
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jaundice warrants early surgical correction of the paraesophageal hernia.
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References: 1. Llaneza PP, Salt WB 2nd, Partyka EK. Extrahepatic biliary obstruction complicating a
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diaphragmatic hiatal hernia with intrathoracic gastric volvulus. Am J Gastroenterol. 1986;81:292-4.
2. Caldeiro JC1, Curcio A, Gigena VC, Barbarosa G. Choledochal semi volvulus with
SC
jaundice due to hiatal hernia. Initial percutaneous management. Acta Gastroenterol Latinoam. 2001;31:329-32.
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3. Lamouliatte H, Bernard PH, Lefebvre P, Boulard A, Arnal JC, Saric J, Quinon A. Hernie hiatale avec volvulus intrathoracique. une cause rare d’ictere obstructif. Gastroenterol
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Clin Biol. 1992; 16:89-91.
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PII: DOI: Reference:
S1542-3565(14)00630-2 10.1016/j.cgh.2014.04.024 YJCGH 53801
To appear in: Clinical Gastroenterology and Hepatology Accepted Date: 21 April 2014 Please cite this article as: Mandaliya R, Amberker D, Breckenridge J, Biliary obstruction from Paraesophageal hernia, Clinical Gastroenterology and Hepatology (2014), doi: 10.1016/ j.cgh.2014.04.024. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. All studies published in Clinical Gastroenterology and Hepatology are embargoed until 3PM ET of the day they are published as corrected proofs on-line. Studies cannot be publicized as accepted manuscripts or uncorrected proofs.
ACCEPTED MANUSCRIPT
Authors: Rohan Mandaliya, M.B.B.S,
RI PT
Department of Medicine, Abington Memorial Hospital, 1200 Old York Road,
SC
PA 19001, USA.
M AN U
Email: [email protected] Phone: 215 588 5949
Deepa Amberker,
Department of Medicine, Abington Memorial Hospital, 1200 Old York Road,
EP
PA 19001,
TE D
M.B.B.S,
USA.
AC C
Email: [email protected] Phone: 215 866 6841
John Breckenridge, MD, Chief,
Department of Radiology,
ACCEPTED MANUSCRIPT
Abington Memorial Hospital, 1200 Old York Road, PA 19001,
RI PT
USA. [email protected]
SC
Corresponding author: Rohan Mandaliya,
M AN U
M.B.B.S, Department of Medicine, Abington Memorial Hospital, 1200 Old York Road,
USA. Email: [email protected]
AC C
EP
Phone: 215 588 5949
TE D
PA 19001,
Funding sources:
Abington Memorial Hospital.
Conflicts of interest: None.
ACCEPTED MANUSCRIPT
Title: Biliary obstruction from Paraesophageal hernia.
RI PT
Case:
An 83 year old female presented with three weeks of painless jaundice. She reported to have
SC
some dyspnea after meals for the past three months. On examination, bowels sounds were audible at the lower half of chest. Abdominal examination was unremarkable. Significant
M AN U
laboratory findings included: Aspartate aminotransferase: 200 U/L, alanine aminotransferase: 150 U/L, alkaline phosphatase: 660 U/L and serum total bilirubin: 20 mg/dl. Chest radiography revealed loops of intestine in thoracic cavity; enterothorax (Panel A). Computed Tomography of the chest and abdomen revealed massive hiatal hernia with protrusion
TE D
of stomach, small intestine, colon, pancreas and a portion of common bile duct into thoracic cavity (Panel B). Gall bladder was massively distended with severe intra and extra hepatic biliary dilatation. (Panel B, red arrow). A partial volvulus of common bile duct was present with the
EP
duct being twisted and running cephalad with acute tapering at the hiatus; thus causing obstructive jaundice (Panel B, green arrow). Panel C (red arrows) shows diaphragm on both the
AC C
sides with massive hiatal hernia. A percutaneous transhepatic cholangiography was performed for biliary decompression. Panel D shows cholangiogram with a biliary catheter in place. It shows common bile duct running superiorly with an abrupt narrowing at the level of hiatus on comparing with the CT scan image and finally ending into duodenum (Panel D, arrow). In Panel D, R represents Right hepatic duct, L: Left hepatic duct, C: Common bile duct, S; stomach, and D: duodenum.
ACCEPTED MANUSCRIPT
Laprotomy confirmed type IV paraesophageal hernia. 50 cm of small bowel was resected due to signs of strangulation. Hernia sac was removed and the contents were reduced into abdominal cavity. The crura were sutured with a mesh and a Nissen fundoplication was performed. Repeat
RI PT
imaging did not show any narrowing of common bile duct. Jaundice improved immediately post operatively.
SC
Jaundice due to biliary obstruction is an extremely rare presentation of paraesophageal hiatal hernia. It was first reported in 1986. 1 However only two cases have been reported thereafter. 2,
M AN U
3. Massive paraesophageal hernia involving intestine may eventually lead to an abnormal cephalad course of common bile duct through diaphragmatic hiatus and may result into extrinsic compression of the bile duct. Percutaneous cholangiography is important to confirm anatomic position of the bile duct as well as for biliary decompression to prevent cholangitis. Evidence of
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jaundice warrants early surgical correction of the paraesophageal hernia.
ACCEPTED MANUSCRIPT
References: 1. Llaneza PP, Salt WB 2nd, Partyka EK. Extrahepatic biliary obstruction complicating a
RI PT
diaphragmatic hiatal hernia with intrathoracic gastric volvulus. Am J Gastroenterol. 1986;81:292-4.
2. Caldeiro JC1, Curcio A, Gigena VC, Barbarosa G. Choledochal semi volvulus with
SC
jaundice due to hiatal hernia. Initial percutaneous management. Acta Gastroenterol Latinoam. 2001;31:329-32.
M AN U
3. Lamouliatte H, Bernard PH, Lefebvre P, Boulard A, Arnal JC, Saric J, Quinon A. Hernie hiatale avec volvulus intrathoracique. une cause rare d’ictere obstructif. Gastroenterol
AC C
EP
TE D
Clin Biol. 1992; 16:89-91.
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EP
TE D
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SC
RI PT
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TE D
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