A Combination of Snare Polypectomy and APC Therapy for Prolapsing Common Bile Duct Adenoma

Abstract

Purpose: Bile duct adenomas are an extremely rare entity with only a few reported cases in the literature and limited knowledge about its natural progression. We present a case of common bile duct (CBD) adenoma which was treated endoscopically with snare polypectomy and Argon Plasma Coagulation (APC). An 83 years old man presented with symptoms of cholangitis. Laboratory values were as follow: Total Bilirubin 6.0 mg/dL, Direct Bilirubin 4.6 mg/dL, AST 87, ALT 69 and Alkaline Phosphatase 157 U/L. Endoscopic retrograde cholangiopancreatography (ERCP) was performed and revealed a filling defect in distal CBD immediately proximal to the papilla. Sphincterotomy was done, balloon sweeps were performed, sludge was removed; however, the filling defect persisted for which biliary stent was placed. Six weeks later ERCP was repeated and cholangiogram revealed filling defect in distal CBD measuring 15 mm. Balloon sweep revealed a distal CBD polyp which was prolapsing out of the duct through the papilla and into the duodenum when the balloon was positioned immediately proximal to the papilla. Piecemeal partial removal of the polyp was performed using snare within the CBD and the sample was sent for histopathology which showed tubulovillous adenoma with no signs of dysplasia. Residual filling defect persisted. A stent was placed and good biliary drainage was noted. Surgical consultation was sought for a possible surgical removal of the polyp, however, the patient was considered a poor surgical candidate due to his multiple co-morbidities and it was decided to repeat ERCP with polypectomy. ERCP after 8 weeks showed fixed distal CBD filling defect consistent with residual polyp. Spy glass choledochoscopy was attempted first, however, because of the location of the polyp immediately proximal to the papilla the procedure was suboptimal in visualizing the lesion. Subsequently, choledochoscopy was performed using forward view gastroscope and the residual polyp tissue was identified, removed with snare and ablated with APC under direct visualization. Subsequent cholangiogram showed no filling defect and a biliary stent was placed after APC therapy to maintain drainage. Stent was removed eight weeks later and cholangiogram revealed normal examination of distal CBD with no evidence of residual polyp or any filling defects. At one year follow up the patient was asymptomatic and had normal liver enzymes. This case illustrates that a combination of snare polypectomy and APC is a reasonable palliative therapy for patients who are not surgical candidates due to other co-morbidities. This approach is also cost effective as it not only relieves the biliary obstruction but also obviates the need for multiple ERCPs.