S3488 The Break-Up: Parting Ways With Impacted Intrahepatic Stones by Electrohydraulic Lithotripsy

Abstract

INTRODUCTION: Intrahepatic gallstones are rare, and can be difficult to access. Impacted or large (≥15mm) stones pose a greater challenge and typically cannot be eradicated with conventional endoscopic techniques. We present a case of left-sided intrahepatic gallstones, treated with cholangioscopy-guided electrohydraulic lithotripsy (EHL). CASE DESCRIPTION/METHODS: A 79-year old White Female with a history of atrial fibrillation on systemic anticoagulation, and GERD presented after two episodes of bright red blood in her stool. She reported four days of weakness, fatigue, and nausea. Vital signs were normal, and physical exam was only remarkable for irregular cardiac rhythm. Complete blood count and comprehensive metabolic panel were unremarkable. CT abdomen showed no bleeding source but revealed new left intrahepatic ductal dilatation. A small hypodense lesion, measuring 0.5 cm was also present anterior to the gallbladder. EGD was normal, and colonoscopy revealed an 18mm sigmoid tubulo-villous adenoma presumed to be the likely bleeding source. MRCP revealed left-sided intrahepatic biliary ductal dilatation and mild extrahepatic biliary duct dilatation without choledocholithiasis or pancreatic ductal dilatation. The patient was referred for EUS with ERCP to rule out cholangiocarcinoma. EUS showed a 9 mm × 7 mm lesion in the left intrahepatic duct, not amenable to FNA. ERCP was then performed, with SpyGlass-guided direct visualization of the biliary tree. Multiple impacted stones were found in the left intrahepatic ducts, measuring up to 20mm (see Figures 1, 2 and 3). EHL was implemented with successful clearance of multiple large stone fragments. Two plastic stents were placed; one in the left hepatic duct to maintain patency, and the other in the ventral pancreatic duct to decrease risk of post ERCP pancreatitis. DISCUSSION: Conventional percutaneous procedures for treating patients with recurrent hepatolithiasis often involve multiple dilation sessions before stone extraction. EHL is superior to conventional management with a high efficacy in clearing hepatolithiasis, and a post-procedure clearance rate up to 91%. The complication rate of EHL is 7-9% with most common complications of pancreatitis, cholangitis, sepsis, and hemobilia. Fortunately, our patient did not experience any complications, and she is scheduled for follow-up ERCP with stent removal in 2-3 months. This case demonstrates EHL via peroral endoscopic cholangioscopy as a highly successful and safe technique for treating hepatolithiasis.Figure 1.: Left intrahepatic stone.Figure 2.: Left intrahepatic stone (2).Figure 3.: EHL therapy of Left intrahepatic stone.