Management of choledocholithiasis with an ultraslim cholangioscope in a patient with possible anaphylaxis to contrast medium

Adverse reactions to contrast medium during endoscopic retrograde cholangiopancreatography (ERCP) are rare [1]; however, once they occur, the subsequent ERCP becomes challenging. Although alternatives using carbon dioxide or gadolinium exist [2] [3], resolution issues persist. Stone removal using a cholangioscope without fluoroscopy or contrast media in pregnant patients has been reported [4]; however, due to the thickness and rigidity of conventional cholangioscopes, this remains problematic. We report on common bile duct (CBD) stone removal without contrast media, using a novel ultraslim cholangioscope with a tip diameter of 2.3 mm (DRES Slim Scope; Japan Lifeline Co., Ltd., Tokyo, Japan) ([Fig. 1]) [5].

Fig. 1 Cholangioscopy system. The cholangioscopy system involves inserting a camera (complementary metal oxide semiconductor type) with a diameter of 1 mm through an ultraslim scope with a diameter of 2.3 mm.

A 31-year-old woman presented to our department with recurrent abdominal pain and elevated biliary enzyme levels, suggesting choledocholithiasis. Computed tomography scans revealed no stones ([Fig. 2]); however, endoscopic ultrasonography (EUS) performed under sedation after pre-administration of antibiotics detected CBD stones ([Fig. 3]). With the patient’s condition stable post-EUS, we proceeded to ERCP.

Fig. 2 Imaging studies. a Ultrasonography showing gallbladder stones. b Computed tomography showing no biliary stones.

Fig. 3 Endoscopic ultrasonography showing common bile duct stones.

Following contrast medium injection into the bile duct, a diagnosis of anaphylaxis was made due to lowering blood pressure, decreased oxygen saturation, and rash developing over the body. The procedure was stopped; epinephrine administration improved the patient’s condition. The contrast medium was likely responsible for the anaphylaxis, despite the possibility of effects from other medications.

On another day, a second ERCP was performed without contrast medium using an ultraslim cholangioscope. Initially, a guidewire was placed in the bile duct using an ultraslim cholangioscope, and then the cholangioscope was inserted. After confirming the presence of stones ([Fig. 4] a), the cholangioscope was withdrawn and stones were removed in a standard manner using a basket catheter under fluoroscopic guidance without contrast medium or a cholangioscope ([Fig. 5]). Finally, the ultraslim cholangioscope verified stone clearance ([Fig. 4] b, [Video 1]).

Fig. 4 Cholangioscope images. a Stones were detected using an ultraslim scope. b After stone removal, the absence of stones in the bile duct was confirmed using the ultraslim scope.

Fig. 5 The stones were removed in a standard manner using a basket catheter under fluoroscopic guidance without contrast media or the cholangioscope.

Successful removal of common bile duct stones without contrast media using a novel ultraslim mother–baby cholangioscope.Video 1

Although ultraslim cholangioscopes do not allow stone removal under direct visualization because of the slim design, they are less invasive in confirming the absence of residual stones after stone removal.

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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Draganov PV, Forsmark CE. Prospective evaluation of adverse reactions to iodine-containing contrast media after ERCP. Gastrointest Endosc 2008; 68: 1098-1101
• 2 Zhang R, Zhao L, Liu Z. et al. Effect of CO2 cholangiography on post-ERCP cholangitis in patients with unresectable malignant hilar obstruction – a prospective, randomized controlled study. Scand J Gastroenterol 2013; 48: 758-763
• 3 Lawrence C, Cotton PB. Gadolinium as an alternative contrast agent for therapeutic ERCP in the iodine-allergic patient. Endoscopy 2009; 41: 564-567
• 4 Burlen J, Amaral AC, Hussain WK. et al. Cholangioscopy-directed basket extraction of bile duct stones in a pregnant patient. Endoscopy 2023; 55: E906-E907
• 5 Tonozuka R, Nagai K, Tsuchiya T. et al. Potential versatile uses of a novel ultra-thin peroral cholangioscope. J Hepatobiliary Pancreat Sci 2023;

Publication History

Article published online:
01 March 2024