A clinical situation in which cholangioscopy can become life-saving
A clinical situation in which cholangioscopy can become life-saving.
Voicu Mercea
Abbreviations:
CBP – the main bile duct
CBIH – intrahepatic bile ducts
CPER – retrograde endoscopic cholangiopancreatography
NPO – nihil per os
PCR – C-reactive protein
Introduction:
At present, cholangioscopy is increasingly used for lithotripsy of difficult stones or for biopsy in the case of stenoses with unexplained etiology. We present a case of septic condition secondary to acute angiocolitis, successfully treated by using the cholangioscope for catheterization with the guidewire of a difficult stenosis of the main biliary tract.
Case presentation:
A 75-year-old patient known to have a mean CBP iatrogenic stenosis (postcholecystectomy – 5 years ago) who had a CPER (unsuccessful) for biliary decompression 3 months before the current presentation and who was complicated by CBP perforation secondary to secondary CPER for which he has followed (successfully) conservative treatment (NPO, antibiotic therapy) is presented in the emergency department for jaundice, fever, pain in the right hypochondrium, chills and altered general condition. Objective examination reveals hypotension, tachycardia, and temporal-spatial disorientation. From a biological point of view, we note leukocytosis with neutrophilia, increased PCR and procalcitonin, predominantly conjugated hyperbilirubinemia as well as increased cholesterol enzyme levels. Ultrasound and computed tomography examination of the abdomen reveals a proximal 1/3 dilation of CBP at 15 mm, CBIH dilation and a marked narrowing area of the CBP lumen in 1/3 average, spread over approx. 5mm. The diagnosis of the current presentation is septic, acute angiocolitis, iatrogenic stenosis of the CBP average, post-CPER perforation with a history (3 months) treated conservatively. Under the given conditions, in which the patient presents a vital risk, a new CPER (with biliary stent mounting) successfully performed is the life-saving therapeutic solution.
Retrograde endoscopic cholangiopancreatography:
After injection of the contrast agent inside the main bile duct, the radiological image shows the area of tight stenosis (blue arrow picture 1) at the level of the average CBP as well as the marked dilation of the proximal CBP of the stenosis.
Next, for approx. For 60 minutes, the catheterization of the stenosis area under the radiologically guided wire is repeated but without success. On the radiological image (picture 2) it can be seen how the guide wire fails to pass the stenosis, which returns back to the papillary orifice.
If the catheterization under radiological control fails, it is decided to use the cholangioscope in order to facilitate the passage of the guide wire through the stenosis area. Video images of the inside of the main bile duct obtained with a cholangioscope show the small distal orifice of the stenosis area (blue arrow picture 3) and a cavity of 4-5 mm remaining after healing of the previous perforation (red arrow picture 3). The acquisition of high quality video images is facilitated by the continuous injection, through a cholangioscope, of saline.
With the cholangioscopic highlighting of the stenosis orifice, it is possible to correctly direct, under video control, the guide wire inserted through the operating channel of the cholangioscope (picture 4) and catheterize the proximal stenosis segment of CBP.
Subsequently, on the guide wire, after the withdrawal of the cholangioscope, the catheterized trajectory is dilated with the 10Fr spark plug as well as the installation of a 10cm / 10Fr plastic biliary stent, thus managing the decompression of the biliary shaft (picture 5, picture 6).
Postoperatively, the patient’s evolution was favorable, she was discharged 7 days after hospitalization.
Conclusion:
Therapeutic cholangioscopy is used for the visual fragmentation of difficult gallstones, for the ablation of bile tumors, as well as for the facilitation of selective catheterization with the guide wire in the intra- and extrahepatic bile ducts. The case presented above highlights the last of the situations, used less frequently, but which can become life-saving when classical catheterization (under radiological control) fails.