A 64-year-old woman with a body mass index of 50 was admitted to our
intensive care unit with the clinical appearance of severe biliary
pancreatitis. Bedside ultrasonography was difficult due to the patient’s
obesity but revealed a dilated common bile duct ([Fig. 1]). Conventional endoscopic retrograde
cholangiography (ERC) with X-rays was considered impossible due to the obesity.
Bedside endosonography (EG 383OUT; Pentax, Tokyo, Japan) was performed.
Endoscopically a swollen papilla excreting pus was seen. Sonographically, large
areas of fluid were demonstrated around the pancreatic body and tail. A small
remainder of undamaged pancreatic tissue was seen in the pancreatic head. The
gallbladder was large and full of small stones. The main hepatic duct was
dilated and filled with stone material. Bedside ERC with a duodenoscope (TJF
160; Olympus, Tokyo, Japan) was performed using contrast ultrasonography
instead of X-radiography. After cannulation of the common bile duct a
second-generation ultrasound contrast agent (Sonovue) was injected through the
papillotome. Bedside ultrasonography (Sequoia, Siemens) demonstrated the
contrast agent in the common bile duct and in the right and left hepatic duct
([Fig. 2]). After papillotomy, stones were
extracted with a basket and a balloon.
Fig. 1 Low-quality
ultrasonography in an obese patient demonstrating a dilated common bile
duct.
Fig. 2 Common hepatic duct with
right and left branch visualized by bedside ultrasonography after the injection
of ultrasound contrast agent through the papillotome.
Therapeutic ERC using X-rays poses a problem not only in obese
patients but also in pregnant women, since fluoroscopy is a risk for the fetus.
Traditionally the problem was solved by wire-guided cannulation by an
experienced endoscopist using as little radiation as possible
[1]
[2]
[3]. In
slim patients ultrasonography without contrast agents may be helpful
[4]. Contrast ultrasonography may combine the advantages
of cholangiography with X-rays and ultrasonography and should be further
explored in this field.
Endoscopy_UCTN_Code_TTT_1AR_2AB
