Wake Forest University School of Medicine Winston-Salem, NC, United States
Award: Presidential Poster Award
Tomas Lucioni, MD, Ella M. LePage, MD, Swati Pawa, MD, Yi Zhou, MD, Rishi Pawa, MD Wake Forest University School of Medicine, Winston-Salem, NC
Introduction: In the setting of altered gastrointestinal anatomy or gastric outlet obstruction, percutaneous transhepatic biliary drainage or invasive surgery have long been the available therapeutic options for biliary tree decompression. EUS guided hepaticogastrostomy (EUS-HG) is a novel endoscopic technique that can provide biliary decompression and aid in diagnosis in such patients.
Case Description/Methods: A 37-year-old male with prior history of cholecystectomy presented to the emergency department with jaundice, pruritis and weight loss. Labs were notable for total bilirubin, 9.4; aspartate aminotransferase (AST), 182; alanine aminotransferase (ALT), 152; and alkaline phosphatase (ALP), 2180. Magnetic resonance cholangiopancreatography (MRCP) showed marked intrahepatic and extra hepatic biliary dilatation with an abrupt cut off at the level of the ampulla. An upper GI endoscopy showed abnormal friable mucosa in the duodenal sweep with significant luminal narrowing (Figure 1A), preventing advancement of the endoscope into the second portion of the duodenum. Cold forceps biopsies obtained from the abnormal appearing duodenal mucosa showed mild cytologic atypia in a background of foveolar metaplasia, and acute and chronic inflammation. Given failure to perform a conventional ERCP due to partial gastric outlet obstruction, an EUS-HG was performed for biliary decompression. On follow-up ERCP at 4 weeks, cholangiogram showed a high-grade stricture in the distal bile duct, measuring 10 mm in length (Figure 1B). Cholangioscopy was performed through the HG tract in an antegrade fashion, and biopsies and brushings obtained from the distal CBD stricture confirmed adenocarcinoma (Figure 1C). Two weeks later, the patient underwent a successful Whipple procedure, with surgical pathology confirming extrahepatic cholangiocarcinoma with tumor invasion into the duodenal submucosa and muscularis propria, pancreas and ampulla (Figure 1D). The HG metal stent was removed 8 weeks post operatively with cholangiogram showing a patent choledochojejunostomy. The patient continues to do well 7 months post resection.
Discussion: EUS-HG is a reasonable and effective way to achieve biliary drainage in patients with inaccessible papilla. The mature HG tract can subsequently be used for antegrade cholangioscopy and biopsies for obtaining tissue diagnosis. Finally, EUS-HG does not prevent patients from undergoing a curative Whipple procedure.
Figure: A. Endoscopic image showing luminal narrowing secondary to tumor invasion. B. Fluoroscopic image showing dilated biliary tree and distal bile duct stricture (red arrow). C. Cholangioscopy with visualization of distal bile duct stricture. D. Invasive adenocarcinoma (arrow heads) involving the common bile duct.
Disclosures: Tomas Lucioni indicated no relevant financial relationships. Ella LePage indicated no relevant financial relationships. Swati Pawa indicated no relevant financial relationships. Yi Zhou indicated no relevant financial relationships. Rishi Pawa indicated no relevant financial relationships.
Tomas Lucioni, MD, Ella M. LePage, MD, Swati Pawa, MD, Yi Zhou, MD, Rishi Pawa, MD. P0065 - EUS-Guided Hepaticogastrostomy for Diagnosis and Management of Distal Malignant Biliary Obstruction Causing Gastric Outlet Obstruction, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.