S1644 A Curious Case of Duodenal Mass Causing Malignant Biliary Obstruction and White Bile

Abstract

Introduction: We describe a case of a duodenal mass causing malignant biliary obstruction and the use of LAMS cholecystoduodenostomy for gallbladder drainage revealing white bile. Case Description/Methods: An 83 year-old male developed orange colored urine and stool for 3 weeks. CA 19-9 was 8,381 U/mL and direct bilirubin was 43.7 mg/dL. CT Abdomen and Pelvis with contrast showed a dilated common bile duct to 1.6cm with narrowing at the ampulla, dilated intrahepatic ducts, and a duodenal mass. ERCP demonstrated a large duodenal ulcerated mass from D1 to D3 and replaced the medial aspect of the duodenal wall. Despite probing the mass with guidewire, bile duct access was unsuccessful. Biopsies showed poorly differentiated adenocarcinoma with mucinous and signet ring cell features (Figure 1A). EUS showed a 4x6cm obstructing polypoid mass in the duodenum (star) with invasion into the distal common bile duct (arrow) resulting in a dilated common bile duct (circle) (Figure 1B). Subsequent LAMS cholecystoduodenostomy was performed for drainage (arrow) (Figure 1C). White bile (clear bile) was noted upon deployment into the gallbladder (star) (Figure 1D). Discussion: White bile in malignant biliary obstruction occurs because the biliary epithelium secretes mucus into bile despite the obstruction, resulting in colorless fluid. White bile has been associated with worse survival in these patients.Figure 1.: (a) duodenal adenocarcinoma with mucinous and signet ring cell features (b) duodenal adenocarcinoma (star) invading the distal common bile duct (arrow) resulting in a dilated common bile duct (circle) (c) LAMS deployment (arrow) within the dilated gallbladder while creating the cholecystoduodenostomy (d) White bile (star) draining through the LAMS.