Kentaro Yoshioka

A 76-year-old man was admitted due to fever and general fatigue. He had undergone three sessions of repeated transcatheter arterial chemoembolization (TACE) with arterial infusion therapy using cisplatin for multiple hepatocellular carcinoma at our hospital. An abdominal CT scan showed a low density area surrounding the spleen. Since US guided drainage revealed that the low density area was filled with bile juice, we performed endoscopic retrograde cholangiopancreatography (ERCP), which showed choledocholithiasis and the leakage of contrast medium from the peripheral intrahepatic bile duct to the extrahepatic area surrounding the spleen. Thus a diagnosis of an extrahepatic biloma surrounding the spleen was made, and an endoscopic biliary drainage (EBD) tube was placed. The biloma rapidly decreased. When endoscopic sphincterotomy (EST) and removal of the bile duct stone were performed after two weeks, ERCP showed no leakage of bile juice to the extrahepatic area. ERCP and EBD were useful for the diagnosis and treatment of an extrahepatic biloma surrounding the spleen.

A 32-year-old man consulted a local hospital for epigastric pain and was diagnosed as obstructive jaundice. He was referred and hospitalized in our hospital. One year ago, he had treatment of pulmonary tuberculosis. Contrast-enhanced abdominal multi-detector row CT (MD-CT) showed a low density mass with an enhanced rim at hepatic portal region. PTBD was done and revealed a smooth narrowing of the upper part of common biliary duct. Based on these results, we suspected that an enlarged lymph node at hepatic portal region caused obstructive jaundice. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of the lymph node at hepatic portal region was done. The pathology of specimen showed caseating granulomas and polymerase chain reaction analysis for tuberculosis of the specimen was positive. Thus we diagnosed as tuberculous lymphadenitis at hepatic portal region which caused obstructive jaundice. Antituberculosis medications were started and the size of the lymph node reduced gradually. After 6 months, biliary drainage tube was removed, and the patient stayed well without development of jaundice.