Management of choledocholithiasis with an ultraslim cholangioscope in a patient with possible anaphylaxis to contrast medium

Adverse reactions to contrast medium during endoscopic retrograde cholangiopancreatography (ERCP) are rare ¹ ; however, once they occur, the subsequent ERCP becomes challenging. Although alternatives using carbon dioxide or gadolinium exist ^{2 3} , resolution issues persist. Stone removal using a cholangioscope without fluoroscopy or contrast media in pregnant patients has been reported ⁴ ; however, due to the thickness and rigidity of conventional cholangioscopes, this remains problematic. We report on common bile duct (CBD) stone removal without contrast media, using a novel ultraslim cholangioscope with a tip diameter of 2.3 mm (DRES Slim Scope; Japan Lifeline Co., Ltd., Tokyo, Japan) ( Fig. 1 ) ⁵ .

Fig. 1.

Cholangioscopy system. The cholangioscopy system involves inserting a camera (complementary metal oxide semiconductor type) with a diameter of 1 mm through an ultraslim scope with a diameter of 2.3 mm.

A 31-year-old woman presented to our department with recurrent abdominal pain and elevated biliary enzyme levels, suggesting choledocholithiasis. Computed tomography scans revealed no stones ( Fig. 2 ); however, endoscopic ultrasonography (EUS) performed under sedation after pre-administration of antibiotics detected CBD stones ( Fig. 3 ). With the patient’s condition stable post-EUS, we proceeded to ERCP.

Fig. 2.

Imaging studies. a Ultrasonography showing gallbladder stones. b Computed tomography showing no biliary stones.

Fig. 3.

Endoscopic ultrasonography showing common bile duct stones.

Following contrast medium injection into the bile duct, a diagnosis of anaphylaxis was made due to lowering blood pressure, decreased oxygen saturation, and rash developing over the body. The procedure was stopped; epinephrine administration improved the patient’s condition. The contrast medium was likely responsible for the anaphylaxis, despite the possibility of effects from other medications.

On another day, a second ERCP was performed without contrast medium using an ultraslim cholangioscope. Initially, a guidewire was placed in the bile duct using an ultraslim cholangioscope, and then the cholangioscope was inserted. After confirming the presence of stones ( Fig. 4 a ), the cholangioscope was withdrawn and stones were removed in a standard manner using a basket catheter under fluoroscopic guidance without contrast medium or a cholangioscope ( Fig. 5 ). Finally, the ultraslim cholangioscope verified stone clearance ( Fig. 4 b , Video 1 ).

Fig. 4.

Cholangioscope images. a Stones were detected using an ultraslim scope. b After stone removal, the absence of stones in the bile duct was confirmed using the ultraslim scope.

Fig. 5.

The stones were removed in a standard manner using a basket catheter under fluoroscopic guidance without contrast media or the cholangioscope.

Download video file ^{(47.1MB, mp4)}

Successful removal of common bile duct stones without contrast media using a novel ultraslim mother–baby cholangioscope.

Video 1

Although ultraslim cholangioscopes do not allow stone removal under direct visualization because of the slim design, they are less invasive in confirming the absence of residual stones after stone removal.

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