S3334 No Fluoroscopy, No Problem: Non-Fluoroscopic, Non-Sonographic Biliary Drainage

Abstract

INTRODUCTION: Acute cholangitis (AC) is classically associated with fever, right upper quadrant pain, and jaundice. Severe AC is a gastrointestinal (GI) emergency that requires urgent intervention. The most common cause of AC is biliary obstruction due to gallstones. The management of severe AC involves early initiation of antibiotics, aggressive resuscitation, and endoscopic retrograde cholangiopancreatography (ERCP). We present a case of severe AC requiring an urgent ERCP that was complicated by fluoroscopy malfunction with successful stent placement. CASE DESCRIPTION/METHODS: A 27-year-old man with a past medical history of autism presented with jaundice and fever. The patient is nonverbal and developed nausea and emesis for 3 days prior to presentation. The patient developed jaundice which prompted medical evaluation. On evaluation, the patient was tachycardic and febrile and was directed to the emergency department (ED). In the ED, abdominal ultrasound showed a CBD measuring 15mm. Initial labs were notable for WBC 21.8k, AST 171, ALT 254, and direct bilirubin >10. The patient was given antibiotics and underwent urgent ERCP. Upon biliary cannulation, pus and bile was released from the papilla. Following cannulation however, the fluoroscopy equipment malfunctioned and was no longer available. Given severe AC and aspiration of pus/bile, one plastic biliary stent was placed under endoscopic guidance. The patient’s labs and vital signs rapidly improved, and he was discharged on oral antibiotics. DISCUSSION: Severe AC requires antibiotics, fluids, and timely ERCP. Although endoscopic ultrasound (EUS) is accurate in diagnosing choledocholithiasis, it is unclear whether EUS-guided biliary drainage is as effective as ERCP. One randomized trial of patients with malignant biliary obstruction showed similar success rates among those undergoing EUS-guided drainage compared to ERCP. Another randomized trial of patients with choledocholithiasis found EUS-guided ERCP without fluoroscopy to be inferior to ERCP with fluoroscopy. In our patient, ERCP with fluoroscopy was unavailable due to a technical malfunction. Although EUS was not attempted, we successfully decompressed the biliary tree with blind stent placement after confirming pus and bile on aspiration. Although ERCP with fluoroscopy is preferred, EUS-guided drainage may be a safe alternative. Biliary decompression without EUS or fluoroscopy may be a viable bedside option in patients too sick for transfer, or in situations where fluoroscopy is unavailable.