Keywords
Obstructive jaundice - Endoscopic ultrasound - Acute cholecystitis
A 60-year-old female with history of hypertension, presented with a two-month history
of jaundice. On admission, total bilirubin levels were significantly elevated to 23 mg/dl,
with no evidence of cholangitis. MRI showed a mass involving the gallbladder, concerning
for malignancy with a complex Bismuth type IV hilar stricture. Endoscopic biliary
drainage was planned. First, an endoscopic retrograde cholangiopancreatography (ERCP)
was performed and access to the right anterior and right posterior system was achieved
with the assistance of hydrophilic 0.032 inch guidewires, which were exchanged with
0.035 inch guidewires. Dilation of the hilar stricture was performed using a biliary
balloon (6 mm diameter) to facilitate passage of stents. Two uncovered Self expanding
metal stent (SEMS) of size 10 mm × 80 mm were placed sequentially in right posterior
and right anterior system, respectively. During the same setting, on EUS dilated left
intrahepatic ducts were identified. A 19 G needle was used to gain access to the left
intrahepatic ducts, followed by advancement of a 0.035 inch guidewire. A 6Fr. cystotome
was then used to create a fistula tract followed by deployment of a partially covered
biliary metal stent (10 mm × 120 mm). Following the endoscopic interventions, the
patient's jaundice resolved, and she was planned for chemotherapy. However, after
two weeks, the patient presented with right upper quadrant pain. Murphy's sign was
positive and ultrasound abdomen showed thickened gallbladder walls suggestive of acute
cholecystitis, likely secondary to biliary metal stents. EUS guided transgastric gallbladder
drainage was performed using a cautery-enhanced lumen apposing metal stent (10mm diameter).
Patient had an uneventful recovery. She received chemotherapy on follow up and remains
asymptomatic 18 months after index procedure.
This case highlights the potential of endoscopic interventions in managing obstructive
jaundice. ERCP and EUS-guided interventions have shown good results in managing complex
cases of malignant obstructive jaundice.[1] These interventions offer a less invasive approach to treatment, leading to reduced
morbidity and faster recovery times compared to traditional surgery.[2] It is important to note that the success of endoscopic interventions depends on
the experience and expertise of the endoscopist performing the procedure.[3] Therefore, patients should seek care from experienced and qualified endoscopists
to ensure the best outcomes. The entire procedure has been shown and explained in
the [Supplementary Video S1].
Supplementary Video S1 Endoscopic video showing ERCP and EUS guided bilateral stenting and EUS guided cholecysto-gastrostomy.
