Endoscopy 2018; 50(07): E163-E164
DOI: 10.1055/a-0599-0280
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© Georg Thieme Verlag KG Stuttgart · New York

Cholangioscopy and electrohydraulic lithotripsy in the management of fistulated pancreatic duct stones

George Goodchild
Division of Gastroenterology, Department of Medicine, University College London Hospitals, London, United Kingdom
,
Sanjay Sivalokanathan
Division of Gastroenterology, Department of Medicine, University College London Hospitals, London, United Kingdom
,
George Webster
Division of Gastroenterology, Department of Medicine, University College London Hospitals, London, United Kingdom
› Author Affiliations
Further Information

Corresponding author

George Webster, MD, FRCP
Gastrointestinal Services
University College Hospital
Ground floor West
250 Euston Road
London, NW1 2PG
UK   
Fax: +44-20-34479218   

Publication History

Publication Date:
09 May 2018 (eFirst)

 

    An 80-year-old man with a history of alcohol-induced chronic calcific pancreatitis presented with new pain and obstructive jaundice. The computed tomography (CT) scan confirmed features of chronic pancreatitis and showed a heavily calcified stone within the bile duct and associated dilatation ([Fig. 1]). Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated dense calcified stones within the extrahepatic bile ducts ([Fig. 2]).

    Zoom Image
    Fig. 1 Computed tomography image showing the features of chronic pancreatitis with a densely calcified stone.
    Zoom Image
    Fig. 2 Endoscopic retrograde cholangiopancreatography showing heavily calcified stones within the extrahepatic ducts.

    Stone extraction was unsuccessful with the extraction balloon and mechanical lithotriptor. A plastic pigtail biliary stent was deployed to assist biliary drainage. Subsequent magnetic resonance cholangiopancreatography (MRCP) showed continuity of the pancreatic duct and bile duct, suggesting the presence of a pancreatobiliary fistula ([Fig. 3]).

    Zoom Image
    Fig. 3 Magnetic resonance cholangiopancreatography confirming the presence of a pancreatobiliary fistula.

    The patient underwent a further ERCP with peroral transpapillary cholangioscopy ([Video 1]). Direct visualization demonstrated a pancreatobiliary fistula associated with the lower bile duct, as well as the presence of white, heavily calcified stones within the extrahepatic bile ducts. Cholangioscopic assessment of the pancreatic duct through the fistula revealed intraluminal papillary projections, consistent with an intraductal papillary mucinous neoplasm (IPMN). Intraductal electrohydraulic lithotripsy (EHL) and subsequent balloon trawl were used to clear the biliary stones. Biopsies confirmed the presence of an IPMN.

    Video 1 Cholangioscopy and electrohydraulic lithotripsy are performed to treat fistulated pancreatic duct stones.

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    Pancreatobiliary fistulas associated with pancreatic IPMN have previously been described; however, we believe this is the first video-reported case of fistulated pancreatolithiasis that was treated with EHL.

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    Competing interests

    None


    Corresponding author

    George Webster, MD, FRCP
    Gastrointestinal Services
    University College Hospital
    Ground floor West
    250 Euston Road
    London, NW1 2PG
    UK   
    Fax: +44-20-34479218   


    Zoom Image
    Fig. 1 Computed tomography image showing the features of chronic pancreatitis with a densely calcified stone.
    Zoom Image
    Fig. 2 Endoscopic retrograde cholangiopancreatography showing heavily calcified stones within the extrahepatic ducts.
    Zoom Image
    Fig. 3 Magnetic resonance cholangiopancreatography confirming the presence of a pancreatobiliary fistula.