A 70 yrs old male was referred to us for evaluation of etiology of obstructive jaundice. Patient had severe icterus and cholestatic symptoms with 15 percent left ventricular ejection fraction and poor risk for surgical evaluation. Under the above circumstances, we decided to evaluate the patient with EUS.

Endoscopy Asia’s Intervention:

  • Diagnosis: Careful EUS evaluation of lower CBD revealed hyperechogenic artifacts at the lower end of CBD suggestive of duodenal diverticulum– intraampullary or para vaterian diverticulum. No evidence of lymphnodes in the supradiaphragmatic posterior mediastinal region was seen. We can see the dilated left hepatic ductal system; this signifies common hepatic ductal involvement. There are no obvious hypoechoic lesions in left lobe liver which is expected in case of malignant lesions. So effective evaluation of mediastinum and left lobe of liver can be done.
  • Treatment: With a linear echo-endoscopy we obtained some tissue for diagnosis. EUS FNA was performed followed by ERCP. Duodenoscopy revealed a large duodenal diverticulum in the second part with an intra diverticular ampulla of vater along with a small perivaterian diverticulum. The access of the ampulla appeared almost impossible initially. However, with some effort selective cannulation of MPD was achieved and a 3 fr stent was placed into the MPD to ensure effective ductal drainage in the process of difficult biliary access and to prevent pancreatitis. A precut sphincterotomy was then performed and CBD could be cannulated after few attempts. Deep cannulation of the left duct was achieved and the stricture at the CHD level felt extremely sclerotic. Cholangiogram showed bismuth type III/ IV stricture leading to independent block of the left and right ductal system. Biliary sphincterotomy was then performed and brushing was taken from the stricture and material was sent for cytological examination. The stricture was then attempt to dilate with various accessories, balloons and soehendra dilators. Finally dilatation was then achieved with a soehendra stent retriever (10 fr). Finally when the tract was dilated a 8.0 cms uncovered self expandable metal stent was then deployed across the stricture. croatia Free flow of contrast was seen from the left ductal system which was opacified.
  • Prognosis of the patient: Patient tolerated the procedure well and there were no intra or immediate post procedural complications and patient was given discharge after an overnight observation.

Endosonographic and ERC findings are suggestive of an advanced mitotic lesion of the gall bladder invading the CHD level leading to bismuth type III/ IV stricture. EUS FNA and brushing material may provide additional information to plan further line of treatment. Placed self expandable uncovered metal biliary stent should alleviate cholestatic symptoms. However, due to extremely difficult position of the ampulla and the nature of the stricture selective cannulation of the right ductal system was not considered safe at present. 

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