Antegrade cholangiogram via cholecystoduodenostomy in biliary pancreatitis

An 89-year-old woman presented with acute nausea and epigastric pain. As part of her workup, abdominal ultrasound was performed which revealed gallbladder wall thickening, pericholecystic fluid, sludge, common bile duct dilatation of 12 mm, and peripancreatic fluid. These findings were suggestive of biliary obstruction from acute pancreatitis. One year prior, she had a similar presentation but was deemed a poor surgical candidate and underwent percutaneous cholecystostomy drainage. On this admission, the patient was again considered unfit for surgery on the basis of her age and severe dementia. A percutaneous cholecystostomy drain was again recommended, but her family declined this option.

Thus, an EUS-guided cholecystoduodenostomy by use of an electrocautery-enhanced lumen-apposing metal stent (LAMS) and ERCP was deemed the best approach for the patient. The EUS confirmed the ultrasonographic findings and additionally revealed bile duct sludge (Fig. 1A). Gallbladder drainage was successfully accomplished via an LAMS (Fig. 1B). ERCP was then attempted but was unsuccessful because of a large periampullary diverticulum (Fig. 1C), which led to failure to locate the ampulla. It was then decided to use the LAMS for potential antegrade rendezvous through the cystic duct. Using a single-use digital scope as a cholecystocope, we passed a guidewire through the cystic duct in the hope of crossing the major papilla to obtain biliary cannulation by means of ERCP. Unfortunately, this was unsuccessful. A 12-mm retrieval balloon was then used to inject contrast medium into the gallbladder and cystic duct to aid in guidewire advancement. Despite fluoroscopy, the guidewire did not traverse the cystic duct. Fortunately, however, reflux of contrast medium was seen in the common bile duct, and an antegrade cholangiogram was obtained (Fig. 1D) (Video 1, available online at www.VideoGIE.org). The duodenoscope was then placed in the periampullary diverticulum, and expression of contrast medium from the papillary orifice was noted (Fig. 1E). ERCP was then completed with retrieval of biliary sludge.

Figure 1.

A, EUS showing gallbladder wall thickening, with common bile duct dilatation and sludge (arrow). B, Endoscopic view of cholecystoduodenostomy via lumen-apposing metal stent. C, Presence of a large periampullary diverticulum leading to failure of location of the papillary orifice and unsuccessful ERCP. D, Antegrade cholangiogram with contrast medium filling the bile duct. E, Expression of contrast medium from papillary orifice.

After the procedure, the patient experienced resolution of her symptoms with normalization of bilirubin and transaminases. One month later, the LAMS was successfully removed. Although this case demonstrates the utility of using EUS-guided cholecystoduodenostomy in managing gallbladder drainage in addition to using this anastomosis as a pathway for biliary rendezvous, our approach could have been simplified with standard biliary rendezvous to access a challenging ampulla followed by conventional ERCP. This, in turn, may have precluded the need for cholecystoduodenostomy via an LAMS and, in hindsight, may have been a more optimal management strategy.

Disclosure

Dr Das and Dr Sachdev are consultants for Boston Scientific. All other authors disclosed no financial relationships relevant to this publication.

Supplementary data

Video 1

Video showing antegrade cholangiogram via cholecystoduodenostomy in biliary pancreatitis.