• A 84 year old female, known diabetic and hypertensive
  • History of upper abdominal pain with low grade fever
  • Referred for evaluation of dilated CBD in a setting of cholelithiasis on other imaging studies with Normal Liver Function Tests
  • EUS – Dilated CBD with a 17 mm stone impacted in the lower CBD
  • Distended gall bladder without sludge and imaging microliths
  • Duodenoscopy- Small peri vaterian diverticulum with normal ampulla
  • ERC- Cholangiogram confirmed the EUS findings Biliary balloon dilatation was carried out with 12-15 mm CRE balloon Biliary Sphincterotomy was performed; free flow of purulent bile was seen  Stone extraction was carried out with stone extraction balloon catheter
  • In view of gall bladder in situ and purulent cholangitis despite a Sphincterotomy a 7 Fr double pig tail stent was placed to ensure free flow of bile

EXPERT COMMENTS

  • Elderly patients with long standing diabetes can present with mild or absent constitutional symptoms in spite of presence of large bile duct stones causing purulent cholangitis
  • Endoscopic extraction of large stones in the presence of a perivaterian diverticulum can be problematic and may lead to inadvertent complications in the presence of severe inflammatory process 1
  • Endoscopic Sphincterotomy followed by Large Balloon Dilatation are promising due to its safety and effective alternative technique for large stone therapy but in experienced hands1
  • Endoscopic mechanical lithotripsy can be employed in refractory cases 2

TAKE HOME MESSAGE

  • Endoscopic ultrasound prior to the ERC helps to anticipate difficult procedures and avoid complications
  • 95% of all CBD stones can be managed effectively by endoscopic methods.3
  • Treatment of difficult CBD stones is accomplished by multimodal approach combining conventional methods such as sphincterotomy, use of extraction balloons and baskets and mechanical lithotripsy with newer techniques such as cholangioscopy guided laser/electro hydraulic lithotripsy.3

REFERENCES

  1. Stefanidis G et al. Endoscopic extraction of large stones, world journal of gastroenterology
  2. CLEVE CLIN J MED 1993; 60:38-42
  3. Trikudanathan G et al. Endoscopic management of CBD stones, world journal of Gastroenterology
Large CBD stone (1.7 mm)

Large CBD stone (1.7 mm)

CBD stone with empty Gall Bladder

CBD stone with empty Gall Bladder

 

 

 

 

 

 

 

 

 

Fluoroscopy showing large CBD stone

Fluoroscopy showing large CBD stone

Wide sphincterotomy with free flow of purulent bile

Wide sphincterotomy with free flow of purulent bile

 

 

 

 

 

 

 

 

 

Balloon sphincteroplasty with a 12-15 mm CRE balloon

Balloon sphincteroplasty with a 12-15 mm CRE balloon

Stone extraction with balloon catheter

Stone extraction with balloon catheter

 

 

 

 

 

 

 

 

 

A 7 Fr double pig tail stent in situ

A 7 Fr double pig tail stent in situ

7 Fr Double pigtail stent in situ

7 Fr Double pigtail stent in situ

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