Introduction

During endoscopic retrograde cholangiopancreatography (ERCP) for biliary indication, difficult biliary cannulation with an unintended access to the main pancreatic duct (PD) increases the risk of post-ERCP pancreatitis (PEP). Both double guidewire technique (DGW) and transpancreatic biliary sphincterotomy (TPBS) can be performed.

Aims & Methods

The purpose of this prospective, randomized, controlled trial is to compare the technical success and adverse events (AEs) rate of these techniques.

Results

Conclusion

In difficult biliary cannulation, TPBS demonstrated a higher success rate and similar safety profile compared with DGW. there was no difference in PEP rate between TPBS and DGW techniques. TPBS is a good alternative in cases of unintended PD cannulation of difficult cannulation.

Clinical Case Summary

A 12-year-old girl, previously healthy, was admitted to pediatric ward with jaundice, itchy skin, and
general weakness for about 10 days. Physical examination revealed jaundice, discrete exophthalmos,
and tachycardia. Laboratory tests showed significantly elevated transaminases, total and conjugated
bilirubin and bile acids, with a mild increase in GTP. INR, ammonia and albumin levels remained within the range. In the first stage of diagnosis, infectious factors (primary and secondary hepatotropic viruses), Wilson's disease and alpha-1-antitrypsin deficiency were ruledout. Elevated ANA antibody levels and increased serum IgG titers have been found, but a liver panel was negative. Imaging studies (MRI) showed no changes in the liver and bile ducts. After consultation with the pediatric gastroenterologist thyroid function tests were performed which revealed: undetectable TSH, high fT4 and fT3. In the course of further diagnostics, positive titers of anti-Tg, anti-TSHr, and anti-TPO antibodies and enlarged thyroid in USG were obtained, which led to a diagnosis of Graves' disease. The treatment included methimazole and propranolol, which stabilized the patient's general condition and improved laboratory parameters within a few days. Currently, the patient is continuing methimazole therapy and remains euthyroid, with liver function tests completely normalized.
The clinical case illustrates the coexistence and mutual influence of liver and thyroid diseases. The patient was initially suspected of having AIH induced by autoimmune thyroid disease. The negative liver panel results could indicate a seronegative variant of AIH. The patient was scheduled for a liver biopsy to establish a definitive diagnosis, but the test was postponed due to a marked improvement in liver parameters as a result of the control of thyrotoxicosis. Complete clinical and laboratory improvement after treatment with thionamides, without the use of typical AIH therapy, argues against this diagnosis.

Disclosure

No conflict of Interest

Clinical Case Summary

A 77-year-old patient with diabetes insipidus underwent an abdominal computed tomography scan due to upper quadrant abdominal pain. The exam showed concentric thickening of the main and intrahepatic bile ducts. A subsequent magnetic resonance cholangiopancreatography, with diffuse thickening of the main and intrahepatic bile ducts, with diffusion restriction and reduced biliary duct caliber, without lithiasis. Due to the suspiecion of a malignant biliary stricture, the patient was proposed for endoscopic retrograde cholangiopancreatography (ERCP) with cholangioscopy. The cholangiogram showed diffuse rarefaction of the intra and extrahepatic bile ducts, with focal dilatation of the intrahepatic bile ducts. After biliary sphincterotomy, cholangioscopy revealed a narrowed main bile duct extending to the hepatic hilum, with neovascularization, and papillary projections. Multiple biopsies were taken and a plastic stent was placed. Cholangioscopy-guided biopsy revealed granulation tissue and stroma with numerous histiocytes and eosinophils. Immunohistochemistry identified histocytes expressing CD68, S100, and CD1a, consistent with biliary involvement by Langerhans Cell Histiocytosis. The procedure was complicated by acute pancreatitis, requiring Intensive Care Unit admission. The patient’s hydroelectrolytic disorders were caused by pituitary involvement (lymphocytic hypophysitis associated with granulomatous disease). The patient started corticosteroid therapy with clinical and analytical improvement.
Langerhans Cell Histiocytosis is characterized by histiocytes proliferation, with progressive fibrosis due to tissue infiltration. In this case, diabetes insipidus was the first disease manifestation, due to lymphocytic hypophysitis. LCH is a rare cause of secondary sclerosing cholangitis, and early diagnosis through cholangioscopy was essential to initiate appropriate systemic therapy, preventing disease progression with multiorgan involvement.

Introduction

Hyponatremia is a frequent complication of cirrhosis and is a prognostic factor correlated with the severity of cirrhosis and influencing survival and the occurrence of complications, but this relationship is not yet well defined.

Aims & Methods

This was a single-centre retrospective descriptive and analytical study, including all cirrhotic patients admitted to our department in ascitic decompensation with hyponatremia between January 2019 and march 2025. The natremia threshold of 130 mmol/l was chosen because it is widely accepted to define hyponatraemia in cirrhotic patients. In our study, we compared 2 groups of patients: group A: fluid restriction + albumin infusion and group B: fluid restriction alone. Predictive factors of hyponatremia development and its impact on the outcome were evaluated. The aim of this study was to identify predictive factors of hyponatremia in cirrhotic patients with ascites, assess its prognostic impact on complications and survival, and compare the effectiveness of two treatment strategies—fluid restriction alone versus fluid restriction combined with albumin infusion—in correcting hyponatremia and improving clinical outcomes.

Results

Out of a total of 127 cirrhotic patients, forty patients with ascites and hyponatraemia (Na < 130 mmol/L) were included in the comparative analysis. These patients were divided into two groups: twenty patients received fluid restriction combined with albumin infusion (group A), and twenty patients received fluid restriction alone (group B). The mean age across both groups was 54.7 years, ranging from 19 to 80 years, with a sex ratio M/F of 0.7.
The causes of liver cirrhosis in our patients were: autoimmune (n=15), viral (n=11), undetermined (n=9), metabolic (n=2), genetic (n=2) and alcoholic (n=1).
Child-Pugh stage was B in 55% and C in 45%. The mean MELD score was 18 [7-48]. The prevalence of dilutional hyponatremia as defined by a serum sodium concentration ≤130 mmol/L or ≤135 mmol/L was 10.5% and 31.4% respectively.
The mean MELD score was 18, ranging from 7 to 48. The prevalence of dilutional hyponatremia, defined as serum sodium ≤130 mmol/L or ≤135 mmol/L, was 10.5% and 31.4%, respectively. A serum sodium level ≤130 mmol/L was significantly associated with more advanced liver disease, including Child-Pugh C (OR=7.84; p<0.001) and MELD >16 (OR=6.76; p=0.001).
Group A demonstrated a significantly greater improvement in natremia (mean increase of 4.5 mmol/L versus 1.2 mmol/L in group B; p=0.02), as well as a lower incidence of complications such as hepatic encephalopathy and hepatorenal syndrome. Although the difference in global survival at one year between the two groups (33.3% in group A vs. 12.5% in group B) The main precipitating factors of hyponatremia identified were excessive diuretic use (n=18), spontaneous bacterial peritonitis (n=12), gastrointestinal bleeding (n=6) and constipation (n=4). In several cases (n=8), multiple triggers were observed concurrently. The presence of hyponatremia was associated with a higher incidence of complications during hospitalization. Survival without complications was significantly reduced in patients with hyponatremia when a serum sodium concentration ≤135 mmol/L was used as the threshold (p=0.012). Moreover, survival free from hepatic encephalopathy and hepatorenal syndrome was significantly lower in hyponatremic patients (p<0.0001).
Analysis of prognostic factors revealed that serum sodium ≤130 mmol/L (HR=2.92; p=0.004), Child-Pugh C stage (HR=3.45; p=0.002), MELD score >18 (HR=2.67; p=0.007), and development of hepatic encephalopathy or hepatorenal syndrome during hospitalization (HR=4.21; p<0.001) were significantly associated with poor outcomes. Treatment of hepatic encephalopathy included systematic use of rifaximin and lactulose alongside management of the underlying precipitating factor. Overall survival at one year was significantly lower in patients with hyponatremia (22.5% vs. 68.7%), as was mean global survival (8.3 months vs. 32.8 months; p<0.0001).

Conclusion

Low serum sodium levels were significantly associated with more advanced liver disease and increased short-term morbidity and mortality in cirrhotic patients with ascites. Our findings suggest that albumin infusion, in addition to fluid restriction, is more effective in correcting hyponatremia and may help reduce the incidence of severe complications such as hepatic encephalopathy and hepatorenal syndrome. Therefore, serum sodium appears to be a valuable prognostic marker. The clinical benefit of correcting hyponatremia should be further confirmed in larger prospective studies.

Clinical Case Summary

A 72-year-old patient with a history of atrial fibrillation on treatment and cirrhosis, presented with subjective fevers and abdominal distention for 2 months. An initial laboratory work-up showed an inflammatory syndrome and a prothrombin level of 40 %. The rest of the work-up was unremarkable. A computed tomography (CT) scan of the abdomen showed dysmorphic liver with signs of portal hypertension and abundant ascites with micronodular infiltration of the greater omentum.
Paracentesis showed ascitic fluid (AF) with total nucleated cells 2400 with 5% neutrophils and 87% lymphocytes and protein levels at 40. Cytology was negative for malignancy.
Initially, the patient was considered for diagnostic laparoscopy to investigate the persistent abdominal symptoms. However, in light of the current epidemiological context, marked by a heightened incidence of tuberculosis in the region, a systematic workup for tuberculosis was prioritized. Direct examination and culture for acid-fast bacilli (AFB) were negative, however Xpert Mtb/Rif was positive. standard chest X-ray showed a normal parenchyma with a small right pleural effusions. Thoracentesis was done and pleural fluid AFB culture was negative.
He was started on isoniazid, rifampin, pyrazinamide and ethambutol and was discharged with a close follow up.