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DOI: 10.1055/s-0034-1393138
Successful biliary drainage with peroral direct cholangioscopy in a patient with Roux-en-Y hepaticojejunostomy for congenital biliary dilatation
Publication History
Publication Date:
19 October 2015 (online)
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The diagnostic and therapeutic effectiveness of combined double-balloon endoscopy with a short endoscope and peroral direct cholangioscopy with an ultraslim endoscope in patients who have altered gastrointestinal anatomy has been demonstrated [1] [2] [3] [4] [5]. We describe successful biliary drainage with a short double-balloon endoscope and peroral direct cholangioscopy in a patient who had cholangitis after surgery for congenital biliary dilatation.
A 61-year-old woman with a surgical history of hepaticojejunostomy and Roux-en-Y reconstruction for congenital biliary dilatation (Todani type IV-A) was admitted because of high fever associated with leukocytosis (white cell count 14 100/μL [normal 3500 – 8500]) and elevated C-reactive protein (21.1 mg/dL [normal 0.0 – 0.3]). Contrast-enhanced computed tomography showed a limited cystic dilatation of the posterior bile duct with multiple stones and peripheral enhancement of the cystic dilatation ([Fig. 1]). Magnetic resonance cholangiopancreatography (MRCP) showed dilatation of both intrahepatic bile ducts that was congenital biliary dilatation ([Fig. 2]).
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Because cholangitis of the posterior bile duct was suspected, the patient underwent double-balloon endoscopy for endoscopic retrograde cholangiography with a short enteroscope (EI-530B; Fujifilm, Tokyo, Japan). The hepaticojejunostomy anastomosis was widely patent ([Fig. 3]). We sought the posterior branch with the guidewire but were unsuccessful because the intrahepatic bile ducts were widely dilated. Therefore, we exchanged the double-balloon endoscope for an ultraslim endoscope (EG-L580NW, outer diameter 5.8 mm, working channel 2.4 mm; Fujifilm), leaving the overtube in place with balloon inflation.
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The ultraslim endoscope was advanced to the hepaticojejunostomy anastomosis and directly inserted into the intrahepatic bile ducts. We identified a membranous stricture of the posterior branch ([Fig. 4]) and cannulated it successfully. Cholangiography revealed multiple stones in the dilated posterior bile duct ([Fig. 5]). We performed biliary drainage with a 6-Fr double-pigtail plastic stent ([Fig. 6]).
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Bacterial culture of the bile juice revealed Escherichia coli overgrowth, and cytologic analysis showed no malignancy. A definitive diagnosis of cholangitis was obtained. Thereafter, the patient’s general condition and the results of clinical analyses rapidly improved.
Endoscopy_UCTN_Code_TTT_1AS_2AD
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References
- 1 Shimatani M, Matsushita M, Takaoka M et al. Effective “short” double-balloon enteroscope for diagnostic and therapeutic ERCP in patients with altered gastrointestinal anatomy: a large case series. Endoscopy 2009; 41: 849-854
- 2 Takaoka M, Shimatani M, Ikeura T et al. Diagnostic and therapeutic procedure with a short double-balloon enteroscope and cholangioscopy in a patient with acute cholangitis due to hepatolithiasis. Gastrointest Endosc 2009; 70: 1277-1279
- 3 Itoi T, Sofuni A, Itokawa F et al. Diagnostic and therapeutic peroral direct cholangioscopy in patients with altered GI anatomy (with video). Gastrointest Endosc 2012; 75: 441-469
- 4 Koshitani T, Matsuda S, Takai K et al. Direct cholangioscopy combined with double-balloon enteroscope-assisted endoscopic retrograde cholangiopancreatography. World J Gastroenterol 2012; 18: 3765-3769
- 5 Matsumoto K, Tsutsumi K, Kato H et al. Effectiveness of peroral direct cholangioscopy using an ultraslim endoscope for the treatment of hepatolithiasis in patients with hepaticojejunostomy (with video). Surg Endosc Jun 27. [Epub ahead of print]