An unusual cause of acute cholangitis

Endoscopic treatment can be challenging in patients presenting with biliary adverse events and a biliodigestive diversion. Multiples approaches have been described. In the past decade, an overall technical success of 80–86 % [1] [2] [3] of enteroscopy-assisted endoscopic retrograde cholangiopancreatography (ERCP) has been described.

Herein, we report the original case of a 65-year-old patient with sickle cell disease who was referred to our department for an unusual acute cholangitis. The patient had undergone biliodigestive anastomosis and Roux-en-Y jejunal loop 25 years ago because of refractory macrolithiasis of the common bile duct. Of note, patients with sickle cell disease are prone to developing biliary adverse events [4].

The patient presented with fever and jaundice. The abdominal computed tomography (CT) scan confirmed the dilatation of the whole biliary tract and revealed a contiguous dilatation of the jejunal loop upstream of an impacted stone of 30 mm ([Fig. 1]). Once the absence of another cause of biliary obstruction was confirmed by magnetic resonance cholangiopancreatography (MRCP) [5], hybrid enteroscopy-assisted ERCP was proposed for the patient.

Fig. 1 Digestive radiological exam revealed a contiguous dilatation of the biliary loop to the biliary tree upstream of a 35-mm impacted stone. a Abdominal computed tomography scan. b Magnetic resonance cholangiopancreatography.

The enteroscopy was performed under general anesthesia, using a 3.2-mm working channel double-balloon enteroscope (EN-580T, Fujifilm, Tokyo, Japan). The push-and-pull technique was used to progress through the small bowel and the biliary loop was easily catheterized. Approximately 40 cm beyond the anastomosis, we identified a large biliary stone completely obstructing the lumen, impacted on a relative stenosis ([Fig. 2]). Lithotripsy was performed using 30-mm braided snare (Lariat; Life Partners Europe, Bagnolet, France) ([Video 1]). After multiple passes, the stone was completely broken up and the obstruction eliminated. The patient recovered well and was discharged 3 days later. The abdominal CT scan performed 1 month later confirmed the absence of residual stones.

Fig. 2 Endoscopic view of a large biliary stone (30 mm) obstructing the whole digestive lumen. Of note, the stone was impacted on a relative non-ulcerated stenosis.

Video 1 An unusual cause of acute cholangitis.

Endoscopy_UCTN_Code_TTT_1AR_2AH

• References

• 1 Itokawa F, Itoi T, Ishii K. et al. Single- and double-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y plus hepaticojejunostomy anastomosis and Whipple resection. Dig Endosc 2014; 2: 136-143
• 2 Tomoda T, Tsutsumi K, Okada H. Comparison between Roux-en-Y patients with and without gastrectomy during endoscopic retrograde cholangiopancreatography using a short double-balloon enteroscope. Dig Endosc 2015; 27: 775
• 3 Blanco-Velasco G, Blancas-Valencia JM, Hernández-Mondragón OV. et al. Treatment of a bile duct leak with ERCP double-balloon enteroscopy in a patient with Roux-en-Y reconstruction. Endoscopy 2016; 48: E197-E198
• 4 Ebert EC, Nagar M, Hagspiel KD. Gastrointestinal and hepatic complications of sickle cell disease. Clin Gastroenterol Hepatol 2010; 8: 483-489
• 5 Manes G, Paspatis G, Aabakken L. et al. Endoscopic management of common bile duct stones: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy 2019; 51: 472-491