This chapter contains sections titled: Background and technique Benign disorders Malignant disorders Lymphoma Detection of ascites Refractory gastric ulcer Benign lesions of the duodenum, ampullary adenomas and ampullary carcinoma Summary References

Introduction: Choledochal cysts (CDCs) are rare congenital dilatations of various segments of the intra-hepatic and/or extrahepatic biliary tract, affecting about 1 in 100000 live births in the West. The majority of CDCs are identified within the first decade of life. When left undiagnosed into adulthood, they are associated with increased risk of malignancy. Case Description/Methods: Seventy-year-old Native American woman presented with 2-weeks of abdominal pain, associated with nausea and anorexia. Labs suggested elevated alkaline phosphatase 203 and lipase > 4000. Noncontrast CT abdomen demonstrated peripancreatic stranding in keeping with mild pancreatitis, gallbladder wall thickening with possible perforation resulting in a hepatic abscess 44 x 18 x 29 mm, and dilated common bile duct (CBD) 21 mm. Following intial resuscitation with fluids and antibiotics, Magnetic Resonance Cholangiopancreatography (MRCP) MRCP was obtained. This showed features of acute interstitial pancreatitis, mildly enlarged peripancreatic lymph nodes, distended gall bladder with diffuse wall thickening and enhancement, focal discontinuity indicating perforation and resultant liver abscess. Proximal CBD was dilated to 21 mm, with abrupt, smooth narrowing of 2.5 cm of distal CBD. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) were deferred. Percutaneous drainage of gall bladder was considered but patient underwent cholecystectomy. Pathology revealed poorly differentiated, diffusely invasive adenocarcinoma on background of extensive high-grade dysplasia, positive cystic duct margin and lymphovascular invasion. Subsequent EUS revealed dilated CBD 20 mm, diffuse echogenicity of pancreas, malignant-appearing lymph nodes. Cholangiogram demonstrated fusiform dilation of CBD in keeping with type I CDC and a 20 mm common pancreatico-biliary channel with anomalous pancreatobiliary junction (APBJ). Patient unfortunately developed metastatic disease with malignant ascites and elected home hospice (Figure 1). Discussion: CDCs are thought to arise due to APBJ with a long common channel, leading to reflux of pancreatic secretions into the biliary tract with resultant injury and cyst formation. Complications of CDCs include biliary stones, recurrent cholangitis, pancreatitis, biliary and hepatic fibrosis, and malignancy. Risk of malignancy increases with age, varies from 2.5% to 21%, and is highest in type 1 CDC. Early diagnosis and surgical excision with biliary diversion is recommended for management of type 1 CDC.Figure 1.: a) Magnetic resonance imaging (MRI) with diffusely thickened and enhancing gall bladder wall with focal discontinuity b) 1.5 x 4.5 cm collection with peripheral enhancement c) Retrospective review of MRI images demonstrating fusiform dilation of bile duct, in keeping with Type 1 Choledochal Cyst (green arrow) d) Retrospective review of the Magnetic Resonance Cholangiopancreatography demonstrating type 1 Choledochal Cyst (green arrow), APBJ (red arrow) and pancreatic duct (yellow arrow) e) Histopathology showing poorly differentiated, diffusely invasive adenocarcinoma of gall bladder with high grade dysplasia f) Cholangiogram demonstrating Type 1 Choledochal Cyst (green arrow) and long common channel (yellow arrow).

Backgrounds/Aims:Data regarding outcomes of endoscopic retrograde cholangiography (ERC) in liver transplant (LT) recipients with biliary-enteric (BE) anastomosis are limited. We report outcomes of ERC and percutaneous transhepatic biliary drainage (PTBD) as first-line therapies in LT recipients with BE anastomosis.Methods:All LT recipients with Roux-BE anastomosis from 2001 to 2020 were divided into ERC and PTBD subgroups. Technical success was defined as the ability to cannulate the bile duct. Clinical success was defined as the ability to perform cholangiography and therapeutic interventions.Results:A total of 36 LT recipients (25 males, age 53.5 ± 13 years) with Roux-BE anastomosis who underwent biliary intervention were identified. The most common indications for a BE anastomosis were primary sclerosing cholangitis (n = 14) and duct size mismatch (n = 10). Among the 29 patients who initially underwent ERC, technical success and clinical success were achieved in 24 (82.8%) and 22 (75.9%) patients, respectively. The initial endoscope used for the ERC was a single balloon enteroscope in 16 patients, a double balloon enteroscope in 7 patients, a pediatric colonoscope in 5 patients, and a conventional reusable duodenoscope in 1 patient. Among the 7 patients who underwent PTBD as the initial therapy, six (85.7%) achieved technical and clinical success (p = 0.57).Conclusions:In LT patients with Roux-BE anastomosis requiring biliary intervention, ERC with a balloon-assisted enteroscope is safe with a success rate comparable to PTBD. Both ERC and PTBD can be considered as first-line therapies for LT recipients with a BE anastomosis.

*Supplementary Figure 1 shows the chemical structure of SBI-183. *Supplementary Figure 2 displays the verification of shRNA KD of QSOX1 by qRT-PCR. *Supplementary Table 1 shows the results from our docking protocols. *Supplementary Figure 3 displays the determination of IC50's by Cell Titer Glo. *Supplementary Table 2 displays cell growth as percentages. *Supplementary Table 3 shows that high dosage with SBI-183 was not toxic to athymic nude mice. *Supplementary Table 4 shows that SBI-183 did not reduce primary tumor growth of MDA-MB-231 in vivo. *Supplementary Figure 4 shows that SBI-183 inhibits metastasis of MDA-MB-231.