A case of endoscopic ultrasonography-guided choledochoduodenostomy for malignant distal bile duct obstruction with upside-down stomach

Endoscopic ultrasonography-guided biliary drainage (EUS-BD) is increasingly being used as a drainage technique in cases where endoscopic retrograde cholangiopancreatography (ERCP) cannot be performed. However, in patients with a massive esophageal hiatal hernia, this poses a risk of mediastinitis due to thoracic puncture. Upside-down stomach, first described in 1926 as type IV diaphragmatic hiatal hernia, is a rare condition in which a large portion of the stomach migrates into the thoracic cavity due to organoaxial rotation [1]. There have been reports of ERCP in patients with upside-down stomach [2] [3] but none of EUS-BD. This is the first report of EUS-BD for distal bile duct obstruction in a patient with pancreatic head cancer and upside-down stomach.

An 84-year-old woman presented to our hospital with the chief complaint of weight loss. Computed tomography revealed a 35-mm tumor in the pancreatic head, and obstruction of the distal bile duct and duodenum by the tumor was suspected ([Fig. 1]). The patient also had an esophageal hiatal hernia of the upside-down stomach type, and almost all of her stomach had prolapsed into the thoracic cavity ([Fig. 2], [Fig. 3]). We decided to attempt endoscopic ultrasonography-guided choledochoduodenostomy (EUS-CDS) along with duodenal stent placement in the papillary region.

Fig. 1 Computed tomography revealed a 35-mm tumor in the pancreatic head, and obstruction of the distal bile duct and duodenum by the tumor was suspected.

Fig. 2 The patient also had a esophageal hiatal hernia of the upside-down stomach type, and almost all of her stomach had prolapsed into the thoracic cavity.

Fig. 3 Schema of this case.

A forward-viewing scope was advanced to the duodenum, and a stiff-type guidewire was advanced to the jejunum ([Fig. 4]). The guidewire was left in place, and the endoscope was removed while the loop for the upside-down stomach was released. A convex endoscope (UCT-260; Olympus, Tokyo, Japan) was then advanced over the wire to the esophagogastric junction. The contrast catheter was advanced, and the endoscope was successfully maneuvered around it to the duodenum. Thereafter, EUS-CDS was performed, and a covered self-expanding metal stent (ZEO STENT, 8 × 60 mm; Zeon Medical Inc., Tokyo, Japan) was placed successfully ([Video 1], [Fig. 5]). This case demonstrates that EUS-BD can be safely performed for malignant distal bile duct obstruction with upside-down stomach if EUS-CDS is used.

Fig. 4 A forward-viewing scope was advanced to the duodenum, and a stiff-type guidewire was advanced to the jejunum. The guidewire was left in place, and the endoscope was removed while the upside-down stomach loop was released.

Fig. 5 A convex endoscope was successfully maneuvered around it to the duodenum. Thereafter, EUS-CDS was performed, and a covered self-expanding metal stent was placed successfully.

Endoscopic ultrasonography-guided choledochoduodenostomy for malignant distal bile duct obstruction with upside-down stomach.Video 1

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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Akerlund A. Hernia diafragmatica hiatus oesophagei vom anatomischen und röntgenologischen Gesichtspunkt. Acta Radiol 1926; 6: 3-22
• 2 Itoi T, Watanabe H, Gotoda T. et al. Therapeutic endoscopic retrograde cholangiopancreatography using a large dilating balloon in a patient with upside-down stomach and bile duct stones (with video). J Hepatobiliary Pancreat Sci 2015; 22: 177-179
• 3 Khirfan K. A rare cause of difficult endoscopic retrograde cholangiopancreatography. Gastroenterology 2020; 158: e10-e11

Publication History

Article published online:
17 May 2024