S2378 A Rare Phenomenon in Endoscopy: A Broken Sampling Brush During Endoscopic Retrograde Cholangiopancreatography and How to Retrieve It

Abstract

INTRODUCTION: Endoscopic Retrograde Cholangiopancreatography (ERCP) is a commonly performed endoscopic procedure in Primary Sclerosing Cholangitis (PSC) patients for dilation of strictures. The known risks of ERCP are bleeding, infection, perforation, and pancreatitis. Brushing of the strictures is routinely performed in PSC patients to rule out malignancy. A previously unknown risk during ERCP is the possibility of breakage of the endoscopic brush. Here we present the case of a rare phenomenon in ERCP. CASE DESCRIPTION/METHODS: A 33-year-old male with a history of Ulcerative Colitis (UC) and PSC presented with jaundice. Laboratory data revealed a total bilirubin of 8 and CA 19–9 of 24. Magnetic resonance cholangiopancreatography (MRCP) showed changes consistent with PSC and distal common bile duct (CBD) stricture with no obvious mass. ERCP was planned. During the ERCP, 5–6mm strictures were noted in the CBD, left, and right hepatic ducts (common in PSC) with pruning of ducts upstream. The distal CBD, right hepatic duct and left duct strictures were sampled with a cytology brush. During the process of sampling, the brush broke off and lodged into the right anterior sectoral duct as evidenced on fluoroscopic images. A 4 mm dilating balloon was inflated next to the broken brush however retrieval was unsuccessful. A histoguide biopsy forceps was used, over the previously placed wire in the right anterior duct, to grasp the broken brush. With careful maneuvering we were able to extract the broken brush and dropped it in the stomach. A forward viewing scope was passed into the stomach and a snare was used to guide the brush into the hood and remove it. The procedure was completed with placement of stents in the right and left duct. There were no post procedure complications and our patient had a benign abdominal exam after the procedure. Use of a histoguide biopsy forceps for this complication prevented the patient from undergoing surgery. DISCUSSION: To our knowledge this is the first reported case of an ERCP sampling brush breaking during a procedure resulting in a foreign body retained in the primary biliary radicles. Review of the current literature showed no case of a broken brush being retrieved from the bile ducts using a histoguide biopsy forceps. Advanced endoscopists performing ERCP in PSC patients with complex biliary strictures should be cognizant of this complication. We are reporting the first such experience of the utility of a histoguide biopsy forceps for retrieval of a sampling brush.Figure 1.: Biliary ducts with broken sampling brush.Figure 2.: Biliary ducts with broken sampling brush.