Endoscopy 2017; 49(10): E260-E261
DOI: 10.1055/s-0043-115895
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Hilar cholangiocarcinoma diagnosed by endoscopic ultrasound-guided hepaticogastrostomy and cholangioscopy

Theodore W. James
Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
,
Ian S. Grimm
Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
,
Todd H. Baron
Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
› Author Affiliations
Further Information

Corresponding author

Todd H. Baron, MD
University of North Carolina, Gastroenterology and Hepatology
101 Manning Drive, Chapel Hill
NC 27514
United States   
Fax: +1-919-843-6899   

Publication History

Publication Date:
31 July 2017 (online)

 

A 77-year-old woman, with a history of Whipple resection 20 years previously for a lesion in the porta hepatis that was later determined to be benign, was found to have elevated bilirubin and alkaline phosphatase on routine laboratory testing, prompting a computed tomography (CT) scan of the abdomen ([Fig. 1]). This showed intrahepatic ductal dilatation and pancreatic duct prominence. The patient was referred for gastroenterological investigation with concern for malignancy versus autoimmune cholangiopathy.

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Fig. 1 Computed tomography (CT) of the abdomen and pelvis shows intrahepatic ductal dilatation and slight prominence of the pancreatic duct, in a 77-year-old woman with a history of Whipple resection 20 years previously.

Single-balloon endoscopic retrograde cholangiopancreatography (ERCP) was attempted but was unable to reach the hepaticojejunostomy. Endoscopic ultrasonography (EUS) was employed to visualize the biliary tree, and demonstrated dilatation of the left intrahepatic bile duct. The duct was punctured under EUS guidance, and a fully covered metal stent was placed from the left hepatic duct into the stomach. A cholangiogram was obtained through the hepaticogastrostomy, and demonstrated hilar stricturing with a patent hepaticojejunostomy ([Fig. 2]). Both the left and right hepatic ducts were decompressed through the hepaticogastrostomy ([Fig. 3]).

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Fig. 2 A cholangiogram obtained through a hepaticogastrostomy demonstrated stricturing at the hilum and a patent hepaticojejunostomy.
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Fig. 3 A biliary duct stent was placed through the hepaticogastrostomy.

A second examination was performed with single-operator cholangioscopy through the hepaticogastrostomy ([Fig. 4]). This demonstrated ulcerated biliary mucosa; brushings were obtained for cytology and biopsies were taken. A plastic biliary stent was placed within the metal stent to allow continued drainage.

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Fig. 4 Cholangioscopy through the hepaticogastrostomy revealed ulcerated, friable, and granular biliary mucosa.

Brush cytology was nondiagnostic; however biopsy tissue from the stricture demonstrated invasive adenocarcinoma. The CA19-9 level at the time of diagnosis was 563 U/mL. The patient was not a candidate for surgical resection, but chemotherapy was initiated. At 4 months after diagnosis, her biliary tree remained adequately decompressed as evidenced by near-normal liver enzyme levels.

A tissue diagnosis is necessary to differentiate hilar cholangiocarcinoma from IgG4 cholangiopathy [1]. This is the first description of hilar cholangiocarcinoma diagnosed via cholangioscopy through an EUS-guided hepaticogastrostomy [2]. The case also serves to demonstrate that both hepatic ducts can be drained through a hepaticogastrostomy into the left duct, which is particularly useful in post-surgical anatomy that limits standard ERCP ([Video 1]).

Video 1 Hilar cholangiocarcinoma diagnosed by endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) and cholangioscopy through the hepaticogastrostomy.


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Competing interests

T. W. James has no competing interests. I. S. Grimm is a consultant for Boston Scientific. T. H. Baron has received travel and research support from Boston Scientific, ConMed, Cook Medical, Gore Medical, and Olympus, and is a consultant and speaker for Cook Endoscopy.

  • References

  • 1 Itoi T, Kamisawa T, Igarashi Y. et al. The role of peroral video cholangioscopy in patients with IgG4-related sclerosing cholangitis. J Gastroenterol 2013; 48: 504-514
  • 2 Okuno N, Hara K, Mizuno N. et al. Advanced technique for biliary stricture diagnosis using endoscopic ultrasound (EUS)-guided hepaticogastrostomy. Endoscopy 2017; 49 (Suppl. 01) E60-E61

Corresponding author

Todd H. Baron, MD
University of North Carolina, Gastroenterology and Hepatology
101 Manning Drive, Chapel Hill
NC 27514
United States   
Fax: +1-919-843-6899   

  • References

  • 1 Itoi T, Kamisawa T, Igarashi Y. et al. The role of peroral video cholangioscopy in patients with IgG4-related sclerosing cholangitis. J Gastroenterol 2013; 48: 504-514
  • 2 Okuno N, Hara K, Mizuno N. et al. Advanced technique for biliary stricture diagnosis using endoscopic ultrasound (EUS)-guided hepaticogastrostomy. Endoscopy 2017; 49 (Suppl. 01) E60-E61

Zoom Image
Fig. 1 Computed tomography (CT) of the abdomen and pelvis shows intrahepatic ductal dilatation and slight prominence of the pancreatic duct, in a 77-year-old woman with a history of Whipple resection 20 years previously.
Zoom Image
Fig. 2 A cholangiogram obtained through a hepaticogastrostomy demonstrated stricturing at the hilum and a patent hepaticojejunostomy.
Zoom Image
Fig. 3 A biliary duct stent was placed through the hepaticogastrostomy.
Zoom Image
Fig. 4 Cholangioscopy through the hepaticogastrostomy revealed ulcerated, friable, and granular biliary mucosa.