So, our next case discussions are going to be at Pat O'Billiary, who knows what we're going to see. I guess Peter's starting us off, and Schaefer-Mock, who's in Moffitt, and Sagarika Satyavada, who is at UT Austin, former fellow with us, fellow extraordinaire, endohepatologist, transplant hepatology-trained. Welcome, all. Hello, hello. We are off to a great start with these wonderful cases this morning, I mean, and what's amazing, no matter how we twist it around, we always end up with ESD, which is great. I love that. I pulled executive privilege, Ashley put me into the third space in those cases, I said, I don't want to do that. I am doing enough of it. I want to do pancreatobiliary, so here I am. And I'll do very similar to Amitabh, I would like you to participate, but I'm not going to pick up on individual people. Mary-Jane, you're safe. You did not choose wisely your seat, I think. But I would very much like you to talk back to me when I ask a question, and I'll be asking a few. So the patient presented with jaundice, fatigue, nausea, vomiting for about a month, and not much else. So she was kind of fitting into the painless jaundice type of presentation. And she got some standard issue labs, this is her basic metabolic panel, and probably what immediately catches your eye is her sodium of 114. Total billy was very high, 26.6, and respective elevation of the alkaline phosphatase. So things appear to be pointing towards obstructive jaundice, normal lipase, normal lactate or minimally elevated lactate. And you see there the serum osmolality, cholesterol was very high. And it was mostly LDL related. MRCP, so this is just one of the shots. So you see a massively dilated biliary system, and also you probably are noticing in the gallbladder there is these large masses. So this is a CT of the abdomen, again you will see the biliary dilation in the liver, and you will see the gallbladder tumors. So it looks like gallbladder cancer, and actually if you can trace it down, the obstruction in the bile duct is towards the mid-bile duct. So of course she was referred to us for ERCP. Let me show you the transectional, it was the same CT, just different view. Biliary dilation, she did not have gastric outlet obstruction despite quite a bit of fluid in the stomach. But that's always a good thing to look at, right? Oh yeah. You're like wondering what the success of your ERCP is when you have pancreatic lesions and you see this big stomach, you're like, huh. Exactly. You know, am I going to get through? Tumor in the gallbladder. Okay. So ERCP was requested and anesthesia canceled it because the sodium was low. That's actually somewhat legit. That's not terrible. Not terrible. Compared to the usual. So let's discuss that. What should you do next? Order additional test is obviously one thing. Anybody wants to shout back to me what else do you want to order as far as the hyponatremia is concerned? I like the nephrology consult. Okay. Nephrology consult. You like the nephrology consult. So look for edematous state. As you know, most, a lot of cases of hyponatremia are related to edematous state, cirrhosis being the one that we deal with routinely. You know that probably the most common maneuver to treat hyponatremia is to initiate a free water restriction by mouth. I put as a joke, the 3% saline. You rarely need to do that. So nephrology consult, Ashley will take on that or tell the anesthesiologist they don't know what the hell they're talking about and proceed with the ERCP. And that's actually what I did. Of course. It did. I didn't use exact same verbiage, but I kindly called them and explained why the sodium was so low. Actually, the sodium is not low. So the question is, what's the cause of the hyponatremia? What additional tests can help the diagnosis? Actually, you don't need any additional tests. I am now showing you some of the tests that I already showed you. Sodium is low. Bile is very high. Cholesterol is very high. LDL is very high. And I also showed you that the serum osmolality was 285. And I know this may sound like back to the future type of conversation, because you probably have tried to suppress this infamous algorithm of how to manage hyponatremia. I don't have a... Oh, I can use the mouse pointer. Of course, the vast majority falls into this hypotonic hyponatremia, where you have three main categories, but there is one branch of this algorithm where they have normal osmolality, such as our patient. And if you look there, there is two main courses. One is high protein. The other one is high lipids. And that's exactly what we're dealing here. This patient, actually, when you calculate their sodium, it is normal. And it is not that the sodium is low, it's the way we measure it. So the measurement of sodium is indirect. The most commonly used technique, which the vast majority of centers use, is indirect ion-specific electrode, I cannot say this word, potentiometry, I guess. Sounds close enough. But the point that I wanted to make is they measure the sodium in the sample, and they factor in that 7% of the sample is lipids, which is normal. So imagine now that you have only that much serum and much more lipids, but you're still calculating based on 7%. So you artificially lower your sodium value, as reported in your Chem 7. So this is a case of pseudo-hyponatremia. And the reason I'm bringing it to you is that every so often in longstanding obstructive genres you will see patients with low sodiums that are actually having pseudo-hyponatremia, and all you need to know is the serum osmolality. If the serum osmolality is normal, you probably don't have to do anything additional. But just to briefly review pseudo-hyponatremia, elevated serum protein, obviously, the various hematologic malignancies can give you that. And elevated lipids, high cholesterol for whatever reasons, high triglycerides for whatever reason, but also lipoprotein X accumulation, which is seen with biliary obstruction. So lipoprotein X has a small amount of triglycerides, free cholesterol, and apolipoprotein C. Basically, increase in cholestasis. And actually, the therapy for that is to relieve the cholestasis, and that's why ERCP is elevated. So now, I'm just recapping what I just said. I will skip that. So now we're coming, we did do the ERCP. This is the initial shot. The wire went into the pancreas. Second shot after initial injection. Any comments from the fellows? What do you see? Tell me. Okay, very well. Somebody has paid close attention. So this is the very long common channel in between the PD and CBD. And it goes by the name of anomalous pancreatobiliary junction. And you can see the outline of the duodenum right here, the air. Can you appreciate it? It's the white, the duodenum is this white or radial lucid. And here is the duodenum wall. And clearly, the junction in between the PD and CBD is outside of the duodenum wall. We also have this stricture here in mid-CBD that will eventually opacify. And this is obviously due to the cancer with dilation up front. So we place a single plastic stand to relieve the obstruction. This was lifted from the internet, from Google, showing you similar picture on MRCP because I did not, we did not get MRCP on our patients. So I could not show you that. And this is an old case of mine that I had one of my patients again showing anomalous pancreatobiliary junction. How often do you see that? It's very uncommon. That's why I like to present this case because it has a very important implications. Okay, so Mary-Jane, you're not going to get away with it. When you see anomalous pancreatobiliary junction, what things immediately should come in mind? Because this is a board question. Every time I have taken the boards, I have gotten a picture of anomalous pancreatobiliary junction. Tell me any association of APPJ with something. High risk of cancer. Of what? Gallbladder. Okay. Bowel duct. Bowel duct. Cancer of the bowel duct and biliary cysts. Okay, and biliary cysts, correct. Okay. I'm coming back. Thank you. So you nailed it. Those are the two associations. There is an association with type 1 colorectal cyst and there is an association with gallbladder cancer. Vivek? You should also call admissions because she's getting pancreatitis. Yes, yes, correct. A major implication. Well, there are some people because there's so many types of bile in their pancreas, their pancreas is sad. It's kind of detuned. It's extensive. But I don't like this. These are difficult biliary cannulations. They can be, and if you don't recognize it, the wire goes into the pancreas and you back out and you reattempt cannulation and you still end up in the pancreas, so they can be quite challenging. And a very nice setup for side branch perforation because the wire keeps going up, you're very happy, you think it's bile duct, you're celebrating, and then you have a side branch perforation. So great case. Yeah, it's a good example of why the obsession with wire guided cannulation can hurt you in this case. Absolutely correct. And I'm glad Raj mentioned that because we'll talk about contrast benefits later on in the day. Right on. I mean, there is this feeling. Yeah, so important to actually, even though it is a risk of pancreatitis, and I agree with you that maybe that risk is lower because the pancreas is used to seeing all the nauseous biliary juices backflowing and refluxing up there, it is important to inject. We had a case maybe about a year or two ago where somebody misidentified that as the biliary hilum, and metal stented the PD. That's a great case. Yeah. Do you get what the discussion is about this? I feel like we're kind of ahead of the wire, the contrast. Do you guys sort of understand the conversation? OK, I just want to make sure that we're not all talking here. Over their head. So a question. Yes, Dennis. Obviously, this is an advanced case in the setting that the patient already developed gallbladder cancer. So a lot of these patients that you may potentially encounter, they present with obstructive jaundice. Some of them may have actually biliary colic type of presentation. And you do the ERCP, and you see this, right? And they have that anomalous junction, but they have a biliary stricture. So you kind of have to do something about it. So my question is, you need to stent the bile duct, but there's going to be a risk of pancreatitis with the anomalous common channel. Do you always, I've been tending to put a PD stent and a biliary stent at the same time. If you put the PD stent, would you go aggressively with a large caliber metal stent? Or what do people do? Right. I mean, Dennis is propelling the discussion one level up. The concern is that when you put the biliary stent here, you occlude the pancreatic orifice, and you give them a bad pancreatitis. And Dennis, if you recall, you may have done ERCPs on her. We had one patient. She was 18 when we started, and she had anomalous pancreatobiliary junction and developed secondary biliary cirrhosis from longstanding obstruction. So she was listed for transplant. Then we start with her with ERCPs and decompress her. And actually, her liver function improved. So now she has cirrhosis, but she's doing well. So she's not bad enough for transplant. But what the hell do we do with her bile duct? So we kept bringing her every three months for plastic stent exchanges in the bile duct without stenting the pancreas. We were concerned about putting metal stent for obvious reasons. So I typically don't stent the pancreas and the bile duct simultaneously, but I shy away from metal stents in the bile duct purely based on theoretical consideration. I don't think anybody has enough data for that. Hey, Peter, two things. One, from the fellows that are taking the boards, they'll actually give you an ABPJMR, and the question will be, what is the next step? It's actually for the patient to surgery or cholecystectomy or something. So just keep that in mind. The second is, if it's a true malignancy, an uncovered metal stent, you think, will be forgiving to the ABPJMR? I mean, I'll give you the short answer. As far as personally biased opinion, I have not placed uncovered metal stent in years. Everything is covered for me, even in people with latex of cystic duct and so forth. I think the risk of acute cholecystitis is there, but it's probably in the latest data support that it's not as common as we once thought. And now with the availability of EOS, drainage of the gallbladder, you have that as a backup plan. My problem with uncovered metal stent is that we have gained significantly on the medical oncology side. So those patients tend to live longer, even with metastatic disease. So they frequently outlive the uncovered metal stent, and then you're stuck with it six months down the road. And what the hell do you do? So it becomes kind of very difficult situation to manage. So I exclusively use fully covered metal stents. If needed, it's very easy to replace. Obviously, biased opinion, but that's how we typically handle it in our unit. Ashley? Yeah, I would say oncology is definitely changing really quickly. And so it is changing a little bit how we do things. But can we just go back to sort of the basic, the wire contrast sort of history of like, when I started training, I don't even know if they had triple lumen catheters. So you had a choice of contrast or wire. And sort of just give the fellows some perspective on what you were all sort of talking about up here, that wire, pancreatitis, contrast. Vivek, are we going to talk about cannulation later on? Yeah, a little bit, a little bit about that. I don't want to steal your show. No, no, you can steal it. It's all right. I mean, there's so many other things to talk about. Don't worry. Not only that, these folks have very short memory span anyway. So after lunch, it'll be like a whole new audience. But just for the fellows, to confuse you further, I almost exclusively use uncovered metal stents because I do not see that cancer patient repeatedly for ERCP. They die, unfortunately, with a median lifespan of six to nine months. So covered metal stents do have a lot of problems. They migrate. They go up and down the ladder. They also occlude. They do cause cholecystitis more than 2%. So this is a great debate. I don't think that this has been fully panned out. But sorry, Peter, you gave me an opportunity, so I took it. Sure, and I deeply regret it. But here we go. Can I just also just add a little bit about what Vivek is talking about? So my practice is a little bit similar. I'll place an uncovered for pancreatic cancer because I don't think those patients do live long. But for cholangio, we've really gotten away from uncovered metal stents because they seem to outlive the stents. And then it causes worse. They're harder. It's longer stents. It's higher up towards the hilum, harder to clear out a tumor ingrowth from the uncovered metal stents. So we've really gotten away from using uncovered metal stents for cholangio. Got it. Good point. The latest guideline, I just reviewed it from the ASG. They still talk about uncovered, but they give the option of plastic as well. So we are migrating away from the uncovered for the hilarious strictures, mainly because patients live longer. And once you've fired that uncovered stent, it's there to stay. Back to a historic perspective. Traditionally, ERCP was done by impacting the cannula into the orifice injecting contrast to get the lay of the land, and then continue to cannulate with the catheter. Eventually, we had the ability to pass a wire through that same catheter. And what Ashley was referring, double lumen versus triple lumen, it was the same lumen that you were injecting, the contrast that you have to pass the wire. Eventually, we got a catheter that had a lumen for contrast, a lumen for the wire. And then that wire-guided cannulation was shown to lead to less pancreatitis, probably because of less trauma to the papilla. That said, if you look at the studies, despite being randomized control studies, they're all unblinded. And one can put a big question mark whether it's the wire versus catheter versus just being gentle with your cannulation, which makes the biggest difference. Anyway, that message got exacerbated so much that people will think that the worst thing that you can do is inject contrast during cannulation, which I think is definitely not the case. And this is a prime example, just a whiff of contrast. And here is a tip that I think will serve you well with TRCP. It's not a true injection. It's puffing it with those initial things. And normally, I will let my assistant inject. But with that initial cannulation, I prefer to do it myself to immediately stop if I'm in the pancreas. It gives me a little bit better control. So here, obviously, my wire first initially went here. And I could have just pulled out and tried to get here. But the wire probably would have kept going into the pancreas. And I will keep banging it. And a little bit of contrast did me a lot of good in this particular case. But to focus on my main message here, I want to make distinction for anomalous pancreatobiliary junction. Very quickly, normally, the junction occurs within the duodenum wall before the muscle layer. And when the junction occurs outside of the duodenum wall, that is called anomalous pancreatobiliary junction. Three types, normal on the left, pancreas to bile duct, and bile duct to pancreas, probably they are all behaving the same. So there is no big difference which one goes first. The important thing is that if you have no evidence of type 1 choledochyl cyst, and this was our case, the risk is of gallbladder cancer. You should recommend prophylactic cholecystectomy in that case. Anomalous pancreatobiliary junction can be associated with type 1 choledochyl cyst. Here is the anomalous junction. This is type 1 choledochyl cyst. In this case, you should recommend bile duct resection. So this is a major difference, cholecystectomy and bile duct resection. So 80% of type 1 choledochyl cyst are associated with type 1, with anomalous pancreatobiliary junction. And that diagnosis can become exceedingly difficult if the patient had a prior cholecystectomy. Because guess what? One of the reasons for bile duct dilation, probably the most common, is prior cholecystectomy. So now the patient comes, do they have type 1 choledochyl cyst? I mean, how many US is probably you guys get referred for dilated bile duct and nothing else, and it's probably just cholecystectomy? If they do have the anomalous pancreatobiliary junction, again, 80% of type 1 choledochyl cyst is associated with that. Then you have secured your diagnosis, and you can send the patient for surgery for bile duct resection, which is a major surgery. Quick reminder about choledochyl cyst. What is type 1? It's fusiform dilation of the extrahepatic biliary tree. This picture doesn't actually do it just because it's not like that oval. Usually it looks like a carrot. You have the bile duct and then a small intrahepatic branches. Type 2 is basically a diverticulum of the bile duct. The distal bile duct is dilated only. That's called choledochyl seal, a biliary sphincterotomy. So you need to typically do in these cases. And you have type 4a and type 4b, which is combination of extrahepatic and intrahepatic and Corollis disease. It's type 5 choledochyl cyst presents with only intrahepatic cysts. This is our case, actually. You see the dysplasia here. And this is a cholangioscopy specimen. In this case, this is an old case of mine. We had Olympus choledochyscope, which had MBI image. And it showed metaplasia. So to wrap it up, anomalous pancreatobiliary junction is associated with type 1 choledochyl cyst. It's a risk of cholangiocarcinoma and surgical resection of the bile duct is indicated. If APBJ is not associated with type 1 choledochyl cyst, the patient is at risk of gallbladder cancer, as our patient. And then you should recommend cholecystectomy if you catch it before the cancer develops. And back to the hyponatremia, what started all this is obstructive jaundice can present with pseudohyponatremia. It has normal serum osmolarity, and there is no need for specific therapy. So these are my slides. If you want to talk about more cannulation, I'll be glad to. There is nothing more subjective than biliary cannulation that everybody does it a little bit different.

jaundice

gallbladder cancer

ERCP

anomalous pancreatobiliary junction

plastic stent

prophylactic cholecystectomy