The Use of Distal Balloon Occlusion Cholangiogram to Evaluate and Treat Difficult Biliary Strictures

Abstract

Purpose: ERCP (endoscopic retrograde cholangiopancreatography) is a useful tool in treatment of malignant and benign biliary strictures. In rare instances, ERCP may be unsuccessful in traversing tight strictures. In this abstract, we describe four cases in which this problem arose and describe the use of distal balloon occlusion cholangiogram to better characterize the strictures as well as allow for biliary interventions. In the first case, a cholangiogram performed in a patient who had a liver transplant showed evidence of a stricture at the anastamotic site through which contrast would not pass. We performed a distal balloon occlusion cholangiogram by inflating the balloon to 12 mm Hg and placed the patient in a reverse Trendelenburg position. Subsequently, contrast flowed into the biliary ductal system proximal to the stricture. We were able to successfully pass the guidewire through the stricture and place a plastic stent. In the second case that was performed in a patient with an anastamotic stricture, contrast would not flow past the stricture. A guidewire also would not advance. A distal balloon occlusion cholangiogram was performed by inflating the balloon to 12 mm Hg and contrast was noted to pass through the stricture. The guidewire was successfully advanced past the narrowing and a stent was placed. In the third case, a patient with cholangiocarcinoma presented for ERCP for stent placement. A high grade obstruction was noted at the bifurcation of the right and left hepatic ducts through which contrast did not pass. A distal balloon occlusion cholangiogram was performed and contrast was noted to pass through the stricture. A stent was then placed to relieve the obstruction. The last case involved a patient who was s/p cholecystectomy and was referred from an outside hospital for possible choledocholithiasis. A previously performed ERC showed lack of contrast passing the mid CBD. The biliary orifice was identified and an extraction balloon catheter was advanced into the distal CBD and an occlusion cholangiogram was performed. A high grade stricture was noted in the proximal CBD. It was dilated using a balloon and a stent was placed across the stricture. The cases above highlight some of the technical difficulties that may arise in evaluating and treating biliary strictures using ERCP. We propose a novel method to help traverse difficult biliary strictures. By performing a distal balloon occlusion cholangiogram, pressure is increased in the bile duct distal to the stricture. This allows for easy flow of contrast through the narrow stricture to a lower pressure system proximal to the stricture. Biliary manipulation with balloon catheters and stents may then be used.