PMC6365396_01
Abbreviations; ERCP: Endoscopic retrograde cholangiopancreatography, CT: computed tomography (a) CT imaging demonstrated dilatation of peripheral side of the left bile ducts. (b) ERCP revealed left-sided bile duct was narrow and the peripheral bile ducts were dilatation. Brushing cytology was performed at the narrow portion, and there was not malignancy in the pathological results.
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Blood biochemistry showed marginally high levels on a liver function test, and computed tomography (CT) imaging revealed dilatation of the peripheral left bile ducts (Fig. 1a). Endoscopic retrograde cholangiopancreatography (ERCP) revealed disruption of contrast medium flow at the hilar part, and enhanced CT showed there was dilatation of left bile duct (Fig. 1).
Extended left lobectomy was performed and hepaticojejunostomy was undertaken as the reconstruction. Histopathological findings revealed uncertain the tumour diagnosed with biliary intraepithelial neoplasia was located in hilar left part of bile duct as the white arrow shown.
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The tumour was pathologically diagnosed with biliary intraepithelial neoplasia at the hilar left part of the bile duct (Fig. 2).
Abbreviation; PTCD: percutaneous trans-hepatic cholangiodrainage. This was the cholangiography by injection via PTCD tube. There was a narrow portion at the hepaticojejunostomy as the white arrow head pointed.
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We determined that the reason was severe repetitive cholangitis because of a slight narrowing at the hepaticojejunostomy (Fig. 3).
At 40 POD, the cross-mixing test was carried out to detect the causes of significant decreases of all coagulation factors. APTT tests are performed on series of mixtures of patient plasma and normal plasma. The result demonstrated there is a convex upward in an immediate reaction as shown in no incubation. The pattern was also shown in delayed reaction as 2hr-incubation at 37  . Similarly, as for PT test, there is a convex upward in an immediate reaction as no incubation. In addition, the line pattern of delayed reaction illustrated a considerable convex upward pattern. These visualised results suggested the existence of coagulation inhibitors, rather than a deficiency of coagulation factors, since the incubation with the normal plasma significantly delayed the recovery of coagulation time.
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This was because the incubation with normal plasma significantly delayed coagulation time (Fig. 4).
Abbreviations: POD: post-operative days, PSL: prednisolone, APTT: activated partial thromboplastin time, PT-INR: prothrombin time-international normalized ratio. We used average 4 units of fresh frozen plasma by 60POD. We started to use PSL from 42POD. The initial dose of PSL was 50 mg/day between 42POD and68POD, and then the figure was decreased to 40 mg/day from 68 to 82POD. This was followed by a decrease of 30 mg/day from 82POD to 93POD. The figure went down to 5 mg/day by 163POD. Due to using PSL, the level of coagulation factors, which were APTT and PT and then the figure was decreased to 40 mg/day from 68 to 82POD. This was followed by a decrease of 30 mg/day from 82POD to 93POD. The figure went down to 5 mg/day by 163POD. Due to using PSL, the level of coagulation factors, which were APTT and PT-INR, considerably decreased and settled between 29POD and 68POD.
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Meanwhile, the level of PT% suddenly went down to 7%, and the figure marginally decreased to under 5% by 18POD (Table 1). This was followed by a dose reduction to 30 mg/day by 93POD and gradual decreases to 5 mg/day by 163POD (Fig. 5).