Alexander Abadir, MD1, Piotr Sowa, MD1, Jason Samarasena, MD, FACG1, John Lee, MD2
1University of California Irvine Medical Center, Orange, CA; 2University of California Irvine, Orange, CA
Introduction: A 66-year-old woman with a history of Roux-en-Y gastric bypass, thromboembolic CVA on dual antiplatelet therapy, and known common bile duct (CBD) stones presented an outside facility 2 months prior complaining of chronic intermittent abdominal pain and jaundice. She was in sepsis due to cholangitis and MRCP showed a 2.1cm CBD stone. ERCP was unsuccessful due to her altered anatomy; therefore, she was treated medically and referred for repeat attempt at ERCP, lithotripsy and bile duct clearance.
Case Description/Methods: ERCP was performed using a double balloon enteroscope (DBE). Ampulla was seen next to a periampullary diverticulum. Retrograde cannulation and cholangiogram showed 2 large stones (Figure 1). Sphincterotomy and balloon dilation was done to 10mm and stone extraction attempted but failed due to their large size. The procedure was repeated with plans to perform cholangioscopy and electrohydraulic lithotripsy (EHL). The ampulla was further dilated using a 14mm balloon to allow direct cholangioscopy using the DBE. Unfortunately, attempt at removing the dilating balloon afterwards failed due to the small lumen size of the scope. Therefore, the scope was removed while keeping the overtube in place. The balloon at the tip of the DBE was removed to facilitate direct cholangioscopy and the scope was readvanced through the overtube to the ampulla. The DBE without the scope balloon passed easily into the CBD. Two stones, a black pigmented and a brown pigmented, were seen (Figure 2) and fragmented using EHL. Stone fragments were cleared in the usual fashion and direct cholangioscopy confirmed bile duct clearance (Figure 3).
Discussion: ERCP is difficult in patients with prior Roux-en-Y gastric bypass. The newest approach is to place a lumen apposing metal stent (LAMS) from the gastric pouch to the remnant stomach then perform antegrade ERCP in the usual fashion. If this is not possible (e.g., unfavorable anatomy, patient, or surgeon refusal) then the only approach is retrograde using a DBE; our patient underwent ERCP prior to the introduction of LAMS. DBE ERCP is cumbersome at best due to the small channel size and limited maneuverability of the scope as well as lack of an elevator. For these reasons, the only way to perform lithotripsy is by direct cholangioscopy after large balloon dilation.
Citation: Alexander Abadir, MD; Piotr Sowa, MD; Jason Samarasena, MD, FACG; John Lee, MD. P0985 - FACILITATING DIRECT CHOLANGIOSCOPY AND LITHOTRIPSY IN A ROUX-EN-Y BYPASS WITH A STUCK DILATION BALLOON. Program No. P0985. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.