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PERORAL CHOLANGIOSCOPY-GUIDED BILIARY STENT PLACEMENT IN A CASE OF A SYMPTOMATIC CYSTIC LESION OF THE COMMON BILE DUCT
TM Saettele, MR Kowal, WP Pais, P Tiwari, ML Bechtold, C Bartalos, D Antillon, MR Antillon
Division of Gastroenterology University of Missouri, Columbia, MO, USA
BACKGROUND: Cholangioscopy has been used for examination of the biliary tract and targeted biopsies. This case used cholangioscopy to place a stent to decompress the biliary tree due to a cystic lesion of the common bile duct (CBD) after a previously failed endoscopic retrograde cholangiopancreatography (ERCP) with attempted stent placement.
Case report: 77 year-old female with multiple medical comorbidities presented with abdominal pain, weight loss, and evidence of biliary obstruction. An abdominal CT demonstrated a 5.8 × 7.5 cm pancreatic head mass encasing the superior mesenteric, celiac, and right hepatic arteries as well as the CBD. EUS was performed and found a 5 × 5 cm cystic pancreatic mass involving the portal confluence and superior mesenteric artery, a 1 × 1 cm peripancreatic lymph node, and ascites. Fine needle aspiration of the mass and ascites were negative for malignant cells. As her icterus and serum bilirubin progressively increased, she underwent an ERCP. ERCP showed a normal pancreatic duct and a disruption of the mid-CBD communicating with a cystic cavity. The wall of the cyst was biopsied at this time. Attempts were made to stent the CBD, but were unsuccessful due to coiling of the guidewire inside the cystic lesion. A 10-Fr 5 cm plastic stent was then placed into the cystic cavity and allowed minimal biliary drain. Four days later, the patient underwent a second ERCP with cholangioscopy using an Olympus video choledocoscope model # CFH-B160 (baby scope). Guidewire access beyond the cystic cavity into the proximal CBD was obtained under direct cholangioscopic visualization, and the proximal biliary tree was grossly dilated. The cyst wall underwent cholangioscopy-guided targeted biopsy. A 7-Fr 10 cm plastic biliary stent was deployed in the CBD across the cystic lesion with good drainage. The targeted biopsy provided a definitive diagnosis of anaplastic large cell lymphoma. Patient opted for palliative care as opposed to aggressive therapy for the lymphoma.
CONCLUSIONS: Cholangioscopy may be used in difficult-to-access biliary tree cases due to deformities of the biliary system from disease processes and provide adequate biliary decompression. Furthermore, cholangioscopy-targeted biopsy can yield diagnosis when traditional EUS guided approach has failed.