Salvage EUS-guided Cholecysto-gastric Drainage for Treatment of Cholangitis Due to Pancreatic Pseudocyst Complicated by Extensive Spleno-porto-caval Thrombosis

Abstract

Purpose: EUS-guided endotherapy is recommended for complicated pancreatic pseudocysts. Presence of portal hypertension (PHT) and collaterals is a relative contraindication for endoscopic drainage. However, when surgery and radiological techniques are impossible, alternate endoscopic approaches were reported. Case: A 37-year-old male was admitted with epigastric pain and jaundice for 10 days. 2mo earlier, he was hospitalized elsewhere with alcoholic pancreatitis complicated by a 5cm pseudocyst and deep vein thrombosis while on TPN. An IVC filter had been deployed to avoid anticoagulation. At present admission, he was jaundiced, febrile and had tender abdomen with hypoperistalsis. Labs: bilirubin 17.9mg/dL, alkaline phosphatase 966IU, amylase 888IU, and lipase 764 IU. There was a 10x6cm pseudocyst in the head of the pancreas on abdominal CT along with dilated pancreatic and extrahepatic bile ducts, ascites and extensive portal, splenic, mesenteric and IVC thrombosis with multiple collaterals around stomach, duodenum, pancreas and spleninc hilum. ERCP failed due to duodenal varices and extensive inflammation along medial duodenal wall. EUS showed chronic calcific pancreatitis with a large pseudocyst obstructing the biliary and pancreatic ducts and complicated by extensive collaterals along the gastroduodenal wall precluding safe EUS-guided access to the pseudocyst. An interdisciplinary meeting (GI, radiology and surgery) concurred extremely high risk with traditional interventions. An EUS-guided cholecystogastric drainage was planned as a salvage procedure to treat cholangitis. The distended gallbladder was punctured with 19G needle transantrally under EUS-guidance to deploy a 6F naso-cholecystic catheter was deployed over a guidewire. With a dramatic improvement in liver function and sepsis, this was subsequently converted to a 7F pig tail stent after 5 days. He was continued on oral intake, antibiotics and started on Coumadin. A repeat attempt at ERCP and EUS-guided access to pseudocyst again failed at 6wks. He remained anicteric and pseudocyst reduced to 4cm on CT at 3mo with complete resolution of splenoportal and IVC thrombosis, and ascites. The pseudocyst completely resolved at 9mo. He is currently awaiting definitive surgery for chronic calcific pancreatitis. Conclusion: Biliary obstruction due to pancreatic pseudocyst is primarily treated by endotherapy. However, presence of extensive portal hypertension and collaterals limit endoscopic options. We described salvage cholecystogastric drainage under EUS-guidance for prompt biliary decompression to treat cholangitis in a patient with large pseudocyst complicated by PHT.