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Create a Free AccountProcedures - ERCP/Cholangioscopy
Impacted gallstone within a cholecystoduodenal fistula: endoscopic laser lithotripsy to the rescue
We share here the case of a 67-year-old man who presented to the emergency department for evaluation of bloating, chills, and dyspepsia for 2 weeks. He was admitted 3 years earlier for similar symptoms, attributed to symptomatic cholelithiasis. Because his symptoms resolved, elective cholecystectomy was not pursued at that time. A CT scan on admission demonstrated pneumobilia with a large stone within the gallbladder and the question of emphysematous cholecystitis versus biliary enteric fistula (Fig. 1).EUS-guided jejuno-enterostomy in a patient with total gastrectomy with Roux-en-Y esophagojejunostomy to facilitate cholangioscopy with electrohydraulic lithotripsy
A 67-year-old man with a history of total gastrectomy followed by Roux-en-Y esophagojejunostomy reconstruction in the setting of gastric adenocarcinoma presented with right-upper-quadrant pain and an abnormal liver function test (LFT) (aspartate aminotransferase 389, alanine aminotransferase 273, alkaline phosphatase 297, total bilirubin 8.70). A liver CT scan was consistent with dilation of the intrahepatic and extrahepatic bile ducts (Figs. 1 and 2; Video 1, available online at www.giejournal.org ).A case of pancreatic duct stones treated with electrohydraulic lithotripsy through a duodenal ulcer
Pancreatic duct stone is a common adverse event associated with chronic pancreatitis. Asymptomatic pancreatic stones can be followed-up by observation, although some cases with severe symptoms require radical treatment, including extracorporeal shock wave lithotripsy, electrohydraulic lithotripsy (EHL), and surgical treatment.1,2 Among these options, EHL is effective, less invasive, and can be performed through a duodenal papilla under pancreatoscopy.3,4 Here, we present a rare case of pancreatic duct stones that were directly treated by an EHL device through a duodenal ulcer.Cholangioscopy in primary sclerosing cholangitis: a case series of benign features
Cholangioscopy is useful in establishing a visual diagnosis of cholangiocarcinoma (CCA), but this is harder to achieve in primary sclerosing cholangitis (PSC) because of the stricture-forming nature of the disease. Furthermore, it can be harder to differentiate malignant from benign features of the underlying inflammation. This case series demonstrates the varied features of nonmalignant inflammatory findings in PSC.A purely endoscopic management approach for Type V Mirizzi syndrome
A cholecystocolonic fistula (CCF) is a communication between the gallbladder (GB) and the colon. When it coexists with any type of Mirizzi syndrome (MS), this is referred to as Type V MS.1 When it is symptomatic, surgical treatment with cholecystectomy, fistula takedown, and possible colonic resection is indicated.2,3 The role of treatment in asymptomatic patients is unclear. Endoscopic management has not been described.Electrohydraulic lithotripsy under the mother-baby cholangioscope system using a colonoscope for large common bile duct stones in a patient with Roux-en-Y reconstruction
Electrohydraulic lithotripsy (EHL) is useful for the treatment of common bile duct (CBD) stones (CBDSs) when stones are larger than 2 cm in diameter or conventional extraction methods have proven ineffective.1 However, EHL requires direct visualization of the CBD, which is often challenging in patients who have undergone Roux-en-Y reconstruction. There have been some reports of EHL under direct cholangioscopy using an enteroscope or ultra-slim upper endoscope for patients with a history of Roux-en-Y reconstruction.Endoscopic retrieval of a proximally migrated biliary stent using extracorporeal shockwave lithotripsy, electrohydraulic lithotripsy, and cholangioscopy with minisnare
A 69-year-old woman with a history of choledocholithiasis underwent ERCP in 2014 with complete removal of intraductal stones and placement of a plastic biliary stent. She was subsequently lost to follow-up without stent removal. Six years later, she presented to an outside hospital with right upper quadrant pain and fever. CT demonstrated intrahepatic and extrahepatic biliary ductal dilation, choledocholithiasis, and a common bile duct stent that had proximally migrated.Complex endoscopic management of gallbladder cancer patient with Bouveret syndrome
A 59-year-old white woman with unresectable metastatic adenocarcinoma of the gallbladder and a malignant hilar stricture managed with palliative uncovered metal stents in a Y-shaped configuration and repeated radiofrequency ablation (RFA) for tumor ingrowth was incidentally found to have duodenal obstruction caused by a large stone precluding a scheduled session of RFA. Because she had no complaints or symptoms related to the presence of the stone, a decision was made to abort the procedure and proceed with further assessment.Overtube-guided electrohydraulic lithotripsy through digital cholangioscopy for difficult biliary stones in a postoperative patient: challenging points with salvage techniques
Enteroscopy-assisted ERCP (E-ERCP) in patients with surgically altered anatomy usually represents a challenge even within the hands of skilled operators, with a success rate ranging from 70% to 90%.1 Management of difficult hepatolithiasis in such patients, using overtube-assisted digital cholangioscopy (DC) with laser lithotripsy, was previously reported.2 We describe here the use of electrohydraulic lithotripsy (EHL) in a similar fashion; however, this case video focuses mostly on challenges we have faced during this demanding procedure.EUS-guided hepaticogastrostomy to facilitate cholangioscopy and electrohydraulic lithotripsy of massive intraductal stones after Roux-en-Y hepaticojejunostomy
ERCP in patients with Roux-en-Y hepaticojejunostomy has suboptimal success rates with forward-viewing endoscopes. A major limitation of balloon enteroscopy–endoscopic retrograde cholangiography (ERC) is the inability to use the standard accessories, which renders treatment of difficult biliary pathologies challenging. EUS-guided hepaticogastrostomy (EUS-HG) allows direct access to the left biliary tree in patients with difficult surgical anatomy.ERCP-directed electrohydraulic lithotripsy for treatment of cystic duct and remnant gallbladder stones
A 55-year-old woman presented to the emergency department with postprandial right upper quadrant pain. An abdominal US demonstrated the presence of multiple hyperechoic, shadowing defects within the gallbladder along with gallbladder wall thickening (Fig. 1). These findings were consistent with acute calculous cholecystitis. The patient was then prepped for laparoscopic cholecystectomy.Management of choledocholithiasis by direct cholangioscopy via freehand intubation using the “J” maneuver
Challenging cases of choledocholithiasis may require multiple modalities to achieve successful extraction of stones. Although conventional cholangioscopy may afford the ability to perform electrohydraulic lithotripsy, the stone burden may still be overwhelming. We demonstrate the application of single-step direct cholangioscopy, with use of a slim upper-endoscope, by freehand intubation using the “J” maneuver, as an additional endoscopic solution for biliary stone management, to avoid the need for surgical bile duct exploration (Video 1, available online at www.VideoGIE.org ).Lumen-apposing metal stent–assisted electrohydraulic lithotripsy and mechanical lithotripsy for cholelithiasis in a nonsurgical patient
Therapeutic applications of EUS are evolving, and the development of novel devices have made EUS-guided gallbladder drainage a feasible and viable option alternative to nonoperative treatments of choice.EUS-guided hepaticojejunostomy with transjejunal per-oral cholangioscopy and electrohydraulic lithotripsy in a patient with complicated choledocholithiasis after Roux-en-Y gastric bypass
Obesity and rapid weight loss after bariatric surgery are established risk factors for gallstone disease. Especially after Roux-en-Y gastric bypass (RYGB), conventional ERCP is rarely successful in patients with symptomatic choledocholithiasis.Electrohydraulic lithotripsy to treat basket impaction of large common bile duct stone
Choledocholithiasis with large bile duct stones greater than 10 mm are at increased risk for failure of traditional endoscopic extraction techniques. One extraction method for large stones is the use of a wire basket to grasp the stone, crush the stone, and then extract the pieces. Occasionally, lithotripsy basket wires can become embedded within the stone, or the wires may fracture. If the wires become embedded, typically an extra-endoscopic mechanical lithotripsy device is used to forcibly crush the stone.Endoscopic treatment of large impacted pancreatic ductal stone using digital pancreatoscopy and electrohydraulic lithotripsy
Patients with chronic pancreatitis can develop pancreatic duct stones. These stones can be asymptomatic when they are small or located in the pancreatic parenchyma, but they can cause problems when they are large enough to obstruct the pancreatic duct, causing worsening abdominal pain, exacerbation of pancreatitis, or both.Direct per-oral cholangioscopy with electrohydraulic lithotripsy for primary severe hepatolithiasis
A 56-year-old Filipino woman with a history of choledocholithiasis status postcholecystectomy with choledochoduodenostomy presented with cholangitis. MRCP revealed a central intrahepatic bile duct stricture with a 5-cm stone proximal to the stricture, causing marked dilatation of the left intrahepatic bile ducts and mild atrophy of the left lateral segment (Fig. 1).
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