EUS – ERCP Interface: Diagnosis and Management of Obstructive Jaundice in case of Ampullary Tumor in setting of Cholangitis – Endoscopy Asia

70 year old female
Significant weight loss within last 6 months
Painless jaundice since 10 days, Associated with on and off Low grade fever
CT Abdomen and pelvis – 8 x 2.2 cm sized enhancing mass lesion in peri Ampullary region
- Involvement of second part of duodenum with peri lesional fat stranding,
- Abrupt cut off of CBD, Central and peripheral IHBRD, Dilated PD
EUS – A4 cm X 1.3 cm sized Ampullary mass with extension into the bile duct
- Dilated Common Bile Duct and Main Pancreatic Duct
- Echogenic bile was seen in the bile duct suggestive of purulent Cholangitis
- A large hypoechoic node was seen in the pericholedochal region
- IHBR appeared dilated in left lobe of liver.
- No evidence of any hypoechoic lesions were seen in the left lobe of liver
ERC – Duodenoscopy revealed Ampullary growth
- Selective cannulation of bile duct was achieved
- Biliary Sphincterotomy was performed and multiple biopsies were taken
- a 6 cm uncovered self expandable metallic stent was placed in the CBD
- Free flow of purulent bile was seen from the placed stent
Diagnosis – Adenocarcinoma

Expert comments:-

Biliary SEMS (short intra pancreatic or covered) do not impede pancreatic resection and may be used for preoperative biliary drainage in patients with malignant CBD obstruction when surgical status is unknown.
Endoscopic treatment of adenomas of the major duodenal papilla is a safe, well tolerated alternative to surgical therapy¹.
In expert hands, complications are rare and surgery is generally not required¹.

Take home message:-

Acute ascending Cholangitis may be an initial presentation of Ampullary tumor and requires urgent biliary decompression with endoscopic biliary drainage².
In purulent Cholangitis, plastic stent tends to block. In such cases Self Expandable Biliary Metal stents provide effective ductal decompression.
In resectable cases, the short biliary self expandable metal stent can be removed at the time of definite surgical intervention.