ERCP for Septic Cholangitis Through a Peg Tube, a Life-Saving Procedure Using an Alternative Access Route to Approach the Biliary Tree When the Regular ERCP Fails

Abstract

Acute cholangitis, is a product of bile stasis and infection of the biliary tract. Diagnostic and therapeutic role of the Endoscopic retrograde cholangiopancreatography (ERCP) has a critical role in the management. Anatomical variation following Roux-en-Y gastric bypass or people who had esophageal obstructions tend to make the early intervention by the ERCP a challenge. We report a case of septic cholangitis in a patient whom the ERCP was achived through a peg tube. Case report: 75-year-old male esophageal cancer & gastrostomy tube for malnutrition presented to the local hospital with fevers. Initial evaluation showed feature of sepsis with a fever, leukopenia, elevation in the liver enzymes & total bilirubin 1.2 and lactic acid 3.2. Ct scan showed a stone in the common bile duct & blood cultures showed Enterobacter cloacae. The patient started on ceftriaxone & transferred to our tertiary center for therapeutic intervention. The patient had a MRCP that demonstrates a 1.3 cm obstructive distal common bile duct stone for which the patient underwent an attempt with ERCP that shortly aborted given partially obstructing esophageal mass. After changing to a small pediatric endoscope, the scope was able to be pass the mass but the procedure terminated due to scope malfunction. Another route to access the biliray system was found; the peg tube was removed after an anchoring system was placed. Following the placement of the anchors an Axio stent was placed & a balloon dilitation was performed inside the stent up to 15 mm in size. Following dilitation an ERCP scope was placed and the papilla was accessed and sphincterotomy was made and stone was removed. After the stone removal, the stent was removed and a peg tube was replaced and the patient tolerated the procedure without any complication & discharged on stable condition. Discussion: ERCP is the treatment of choice in establishing biliary drainage in acute cholangitis. In the setting of anatomical variation, the success rate dramatically dropped below 70% when compare it to the traditional ERCP 90-95%. The literature showed that the success rate is higher using surgically created route through the stomach as a mature gastrostomy, trans-gastric or laproscopic- assisted port are all well tolerated. In patient with limited access for the traditional ERCP, alternative routes can allow the gastroenterologist to drain the blockage; such intervention can improve the mortality & morbidty.