Endoscopy 2021; 53(01): E31-E32
DOI: 10.1055/a-1173-8067
E-Videos

An unexpected diagnosis of undetermined biliary stenosis via endoscopic ultrasound

Jérémie Albouys
1  Gastroentérologie et endoscopie digestive, CHU Dupuytren, Limoges, France
,
Sophie Geyl
1  Gastroentérologie et endoscopie digestive, CHU Dupuytren, Limoges, France
,
Rebecca Rodrigues
1  Gastroentérologie et endoscopie digestive, CHU Dupuytren, Limoges, France
,
Véronique Loustaud-Ratti
1  Gastroentérologie et endoscopie digestive, CHU Dupuytren, Limoges, France
,
Romain Legros
1  Gastroentérologie et endoscopie digestive, CHU Dupuytren, Limoges, France
,
Mathieu Pioche
2  Unité d’endoscopie digestive, service de Gastroentérologie – Pavillon H, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
,
Jérémie Jacques
1  Gastroentérologie et endoscopie digestive, CHU Dupuytren, Limoges, France
› Author Affiliations
 

Endoscopic diagnosis of indeterminate biliary stenosis is difficult, often requiring repeat examinations [1]. Among rare causes of such stenoses, portal biliopathy is exceptional; 65 – 85 % of patients with extrahepatic portal obstructions exhibit no symptoms [2] [3]. Physiopathologically, the condition is caused by dilation of both plexuses that return the blood of the main bile duct. This develops secondarily to portal hypertension and compresses the common bile duct.

Here, we report the case of a 52-year-old patient with a recent history of severe acute pancreatitis complicated by portal thrombosis and infected necrosis drained via a lumen-apposing metal stent. During follow-up several months later, he exhibited cholestasis in hepatic testing, and computed tomography and magnetic resonance imaging revealed dilation of the main biliary tract but no visible obstacle, as well as a possible distal stricture ([Fig. 1]). Endoscopic ultrasound revealed a dilated main bile duct with a thickened and edematous wall, which was most noticeable at the level of the papilla, suggestive of an inflammatory or tumor cause ([Fig. 2]). Doppler ultrasound showed that the hypoechogenic thickening was attributable to main bile duct hypervascularization ([Fig. 3]). Transduodenal endoscopic ultrasound revealed several dilated vessels compressing the lower bile duct ([Video 1]). Endoscopic management of such stenoses is associated with a very high risk of hemorrhage [4], especially in patients who have undergone sphincterotomy. We placed a portosystemic shunt in this patient.

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Fig. 1 Computed tomographic scan and magnetic resonance imaging of biliary tract.
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Fig. 2 Bile duct thickening.
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Fig. 3 Bile duct hypervascularization.

Video 1 An unexpected diagnosis when endoscopic ultrasound was used to explore a case of undetermined biliary stenosis.


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Competing interests

Mathieu Pioche: scientific consultant for Olympus, Boston and 3D matrix, ESD training with Cook and Olympus. Véronique Loustaud-Ratti: advisory board and speaking for Gilead and Abbvie. Sophie Geyl: speaking for Abbvie and Ipsen, invitation (conference) for Amgen. Jérémie Jacques and Romain Legros: scientific consultant for Boston and Olympus.


Corresponding author

Jérémie Albouys, MD
Service d’Hépato-gastroentérologie
CHU Dupuytren 87042, Limoges
France   
Fax: +33-5-55058733   

Publication History

Publication Date:
29 May 2020 (online)

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany


Zoom Image
Fig. 1 Computed tomographic scan and magnetic resonance imaging of biliary tract.
Zoom Image
Fig. 2 Bile duct thickening.
Zoom Image
Fig. 3 Bile duct hypervascularization.