Since it was first described in 2001 [1], endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) has been increasingly
used as an alternative for biliary decompression after failed endoscopic retrograde
cholangiopancreatography (ERCP). EUS-CDS has an overall technical success rate of
more than 90 % [2]
[3], but puncturing the common bile duct (CBD) can be challenging in patients with hemobilia
because it presents as a heterogeneous echogenicity. Here, we present a patient for
whom EUS-CDS was successfully performed under contrast-enhanced harmonic EUS (CH-EUS)
guidance.
A female patient in her eighties with advanced duodenal cancer was referred to our
hospital for treatment of recurrent obstructive jaundice. She had previously undergone
duodenal metal stent placement and an external gallbladder drainage catheter had been
placed for biliary obstruction due to direct cancer invasion of the ampulla. An abdominal
computed tomography (CT) scan revealed bile duct dilatation and high-density components
in the CBD, suggesting hemobilia ([Fig. 1]). As her CT scan showed a dilat-ed CBD, we elected to perform EUS-CDS.
Fig. 1 Abdominal computed tomography (CT) scan showing bile duct dilatation and high-density
components in the common bile duct, suggesting hemobilia (arrowheads).
B-mode EUS revealed heterogeneous echogenicity in the CBD, but the visualization was
poor. To determine whether there was active bleeding and to delineate the CBD from
the surrounding tissues, we performed CH-EUS. Immediately after intravenous infusion
of 0.015 mL/kg of a sonographic contrast agent (Sonazoid; Daiichi-Sankyo, Tokyo, Japan),
we identified the dilated CBD as an avascular structure, with a clear margin ([Fig. 2]; [Video 1]). There was no pooling of contrast agent in the CBD, so it was punctured with a
19-gauge aspiration needle ([Fig. 3 a]). After dilating the fistula, we successfully deployed a self-expandable covered
metal stent (Niti-S Biliary Covered Stent; 8 × 60 mm; Taewoong Medical, Seoul, South
Korea; [Fig. 3 b]). Following this procedure, the patient’s condition improved within a few days.
Fig. 2 Endoscopic ultrasound (EUS) images showing: a in B-mode, heterogeneous echogenicity in the common bile duct, but poor visualization;
b with contrast-enhanced harmonic EUS, the common bile duct as an avascular structure
with a clear margin and no pooling of contrast agent in the common bile duct.
Video 1 A sonographic contrast agent (Sonazoid) was injected to determine whether there was
active bleeding and to delineate the common bile duct (CBD) from the surrounding tissues
during endoscopic ultrasound-guided choledochoduodenostomy. After intravenous infusion
of Sonazoid, the CBD was clearly identified, allowing choledochoduodenostomy to be
safely performed.
Fig. 3 Choledochoduodenostomy guided by real-time contrast-enhanced harmonic endoscopic
ultrasound showing: a the dilated common bile duct being punctured with a 19-gauge aspiration needle (arrowheads);
b successful deployment of a covered metal stent between the common bile duct and the
duodenum (arrowheads) after dilation of the fistula.
To the best of our knowledge, this is the first report of CDS being guided by CH-EUS.
CH-EUS may be useful for patients with hemobilia in helping to clearly visualize the
CBD.
Endoscopy_UCTN_Code_TTT_1AS_2AD
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high quality video and all
contributions are freely accessible online.
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos
