A 57-year-old woman with an allergy to iodinated contrast presented
with intermittent right upper quadrant pain. Laboratory test results were as
follows: total bilirubin 4 mg/dL, alkaline phosphatase 164 mg/dL,
and normal amylase, aspartate transaminase, and alanine transaminase levels. A
solitary 1-cm calculus was identified in the distal common bile duct on
magnetic resonance imaging ([Fig. 1]);
linear-array endosonography confirmed the presence of a 0.9-cm calculus ([Fig. 2]). Using a needle-knife, a 0.035-inch guide
wire, and a 12-mm extraction balloon (all Boston Scientific, Natick,
Massachusetts, USA), the bile duct was cannulated, the papilotomy extended, and
the stone extracted, all under endoscopic ultrasound (EUS) guidance ([Fig. 3], [4]). Standard
cannulation under EUS guidance was unsuccessful, probably due to the presence
of stone in the distal common bile duct/ampulla. There were no complications
resulting from the endocopic intervention. The patient underwent an uneventful
laparoscopic cholecystectomy and no residual stones were noted at
intraoperative cholangiography.
Fig. 1 Magnetic resonance imaging view
of a distal common bile duct stone.
Fig. 2 Endoscopic ultrasound (EUS)
demonstrated a stone in the distal common bile duct.
Fig. 3 A fistulotomy was performed
under EUS guidance.
Fig. 4 EUS image of the
needle-knife.
The injection of contrast during endoscopic retrograde
cholangiopancreatography (ERCP) has been linked to post-ERCP pancreatitis. In
addition, in patients with contrast allergy, ERCP might have to be delayed for
up to 12 hours until steroids have been administered, delaying emergency
therapeutic interventions in patients with serious conditions such as severe
cholangitis or gallstone pancreatitis [1]
[2]
[3]. Fluoroscopy is also expensive
and is a limited resource, given that its availability is often controlled by
radiology departments. At the same time, EUS is becoming widely available and
its range of indications is expanding [4]. We have
demonstrated the feasibility of perfoming therapeutic interventions in the bile
duct under EUS guidance alone, without fluoroscopy and contrast injection. This
strategy has potential applications in pregnant women requiring therpaeutic
interventions in the bile duct, in patients with contrast allergy who require
emergency ERCP, and also in patients with bile duct abnormalities identified at
EUS in whom an additional ERCP could be avoided using this technique
[5].
Endoscopy_UCTN_Code_TTT_1AS_2AD
Endoscopy_UCTN_Code_TTT_1AR_2AH
