Endoscopic ultrasound (EUS)-guided biliary access has recently been indicated not
only for malignant biliary obstruction but also for benign biliary stricture [1]
[2]
[3]
[4]. Among EUS-guided biliary drainage routes, EUS-guided hepaticogastrostomy (HGS)
may be the most challenging procedure because the diameter of the intrahepatic bile
duct is smaller than the extrahepatic bile duct. In addition, if the intrahepatic
bile duct is not dilated, such as in benign biliary disease, EUS-guided access may
be challenging. Recently, EUS-HGS under contrast-enhanced EUS has been reported as
a novel technique [5]. The concept of this technique is to obtain a clear image of the bile duct. We herein
describe technical tips for contrast-enhanced EUS-guided access to a nondilated bile
duct.
A 55-year-old woman was admitted to our hospital because of liver abscess. She had
undergone pancreaticoduodenostomy for intraductal papillary mucinous neoplasm 3 years
previously. She also experienced frequent cholangitis due to hepaticojejunum stricture
(HJS), which can lead to liver abscess. The liver abscess was treated by percutaneous
transhepatic abscess drainage. After this procedure, an EUS-guided approach was attempted
to treat the HJS ([Video 1]).
Video 1 To detect the biliary tracts, sonographic contrast agent was administered intravenously.
The intrahepatic bile duct was visualized and carefully punctured using a 19-gauge
aspiration needle. After the cholangiogram was obtained, a 0.025-inch guidewire was
carefully inserted into the biliary tract. Finally, a covered metal stent was deployed
from the intrahepatic bile duct to the stomach.
Dilatation of the intrahepatic bile duct was not observed ([Fig. 1 a]). To detect the biliary tracts, sonographic contrast agent (Sonazoid; Daiichi-Sankyo,
Tokyo, Japan) was intravenously administered. The narrow intrahepatic bile duct was
visualized ([Fig. 1 b]). This bile duct was carefully punctured using a 19-gauge aspiration needle. Bile
juice could not be aspirated. A small amount of normal saline was injected, and because
no resistance to the injection was observed, the contrast medium was injected ([Fig. 2 a]). Finally, a covered metal stent was deployed from the intrahepatic bile duct to
the stomach without any adverse events ([Fig. 2 b, c]).
Fig. 1 Endoscopic ultrasound imaging. a The intrahepatic bile duct was not dilated. b After intravenous administration of sonographic contrast agent, the narrow intrahepatic
bile duct was visualized (arrow).
Fig. 2 Contrast enhancement. a The contrast medium was injected and a cholangiogram was successfully obtained. b A 0.025-inch guidewire was successfully inserted into the biliary tract. c A covered metal stent was deployed from the intrahepatic bile duct to the stomach.
Contrast-enhanced EUS-guided biliary drainage has clinical impact not only for obtaining
a clear image of the bile duct but also in cases of nondilated bile ducts.
Endoscopy_UCTN_Code_TTT_1AS_2AD
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in gastroenterological endoscopy. All papers include a high
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