Endoscopic Retrograde Cholangiopancreatography (ERCP) in an Intrathoracic Stomach: Novel Use of a Full Spectrum Endoscopy (FUSE) Stiffening Wire

Abstract

A 96-year-old highly functional woman presented to the ED after a fall at home and was found to be febrile (38.4°C) with right upper quadrant pain. Laboratory evaluation remarkable for a total bilirubin of 2.2 mg/dL, direct bilirubin 1.5 mg/dL, AST 475 U/L, ALT 157 U/L, and alkaline phosphatase 214 U/L. Due to concern for cholangitis she was started on antibiotics and underwent an MRCP which displayed numerous gallbladder stones as well as two stones in the common bile duct measuring up to 1.2 cm. The patient underwent an attempted ERCP, but due to altered anatomy, the duodenoscope could not be passed through the antrum, despite abdominal pressure and position changes (Images A1&2). The upper endoscope was substituted and the pylorus was located and passed into a normal duodenum with difficulty, but the ampulla could not be visualized. Her previous chest imaging was reviewed, which confirmed a complete intrathoracic stomach (Image B). ERCP was reattempted with a different endoscopist the following day, but the duodenoscope was unable to be passed due to excessive looping. The scope was withdrawn, and an Endochoice Drivewire, normally used to stiffen a full spectrum colonoscope (FUSE), was passed through the scope. The duodenoscope was reintroduced, and was then able to be advanced to the ampulla with successful cannulation of the bile duct (Image C). A subsequent cholangiogram revealed a diffusely dilated common bile duct, with a large obstructing stone. A sphincterotomy was performed with successful stone extraction. The patient improved after the procedure, with all laboratories returning to baseline and eventually discharged home. An intrathoracic stomach is a rare condition resulting from a large herniation of a substantial portion of the stomach into the chest through a defect in the diaphragm. It is typically found incidentally on radiographic or endoscopic evaluation. Presentations of this condition form a wide spectrum, as patients may have no clinical symptoms but serious complications such as incarceration of the stomach may also arise in the setting of the herniated stomach leading to volvulus. Endoscopic difficulties have also been reported. In our case, balloon enteroscopy was unlikely to be successful, due to failure to visualize the ampulla with a forward viewing scope. Use of a stiffening Drivewire offers a novel modality and approach to patients with abnormal anatomy that may assist in the management of these challenging cases.Figure