Diagnostic and Therapeutic Benefits of Direct Visualization of the Biliary Tree

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) uses radiographs to image the biliary tree, but a challenge with ERCP is the inability to directly visualize the biliary tree. The emergence of direct peroral cholangioscope technology (DPCT) allows direct visualization of the bile duct using a small scope. This report describes the successful treatment of a cystic duct stone using DCPT that was otherwise not amenable to ERCP. A 54-year-old female presented with a 3-week history of low-grade fevers, RUQ pain, and melena. Labs showed elevated alkaline phosphatase of 1227 IU/L. CT showed a 10 cm x 8 cm liver mass in the right lobe concerning for abscess vs. necrotic cancer. Magnetic resonance cholangiopancreatography (MRCP) revealed debris, common bile duct of 12 mm, and cholelithiasis. ERCP revealed hemobilia, and a plastic stent was placed. Biopsy of the liver mass showed necrotic material. After admission to our facility, she developed cholangitis due to stent migration. ERCP showed blood clots filling the bile duct and a metal stent was placed to facilitate drainage. The patient's condition stabilized, and she was discharged on antibiotics. She was lost to follow-up, and later presented with acute cholecystitis requiring cholecystectomy. Interestingly, her liver abscess had completely resolved. Four weeks later, an elective ERCP was performed and the previously placed metal stent was removed. Initial cholangiogram revealed no pathology and a balloon sweep revealed minimal amount of sludge. Due to unclear etiology of her illness, DPCT was utilized and a large stone was discovered at the orifice of the cystic duct which was inconspicuous on MRCP and ERCP cholangiograms. Guided via DCPT, a long wire was passed into the cystic duct. (Fig. 1) After minor manipulation, stone was dislodged and removed. (Fig. 2A & B) At 6-month follow-up, patient was asymptomatic. This was a challenging case, as the etiology of the patient's liver abscess and hemobilia proved difficult, especially due to the inability to exclude neoplasm. Standard visualizing techniques were non-diagnostic, but DPCT was integral in both diagnosis and therapy. Undetected stones by ERCP may be higher than expected, and DPCT is successful in treating difficult stones due to its ease of use, safety profile, and high utility. Gastroenterologists should consider implementation of DPCT for diagnosis and therapy, especially in the setting of challenging cases.1391_A.tif Figure 1: DPCT used to guide long wire into the cystic duct1391_B.tif Figure 2:A. DPCT used to reveal large-impact stone at the orifice of the cystic duct1391_C.tif Figure 3: Extracted stone in the duodenum