Intraductal biliary polypectomy performed with a nasogastroscope

Introduction

A 79-year-old man was admitted to emergency for septic shock due to angiocholitis, with acute renal failure, hyperlactatemia, and thrombopenia. His medical history included a cholecystectomy for acute cholecystitis and removal of choledocholithiasis that occurred more than 10 years ago.

Case report

Computed tomography confirmed the recurrence of cholelithiasis in the common bile duct (CBD) and in the dilated right hepatic duct associated with atrophy of S6 – 7 hepatic segments ([Fig. 1]). Multiple stones and pus were extracted from the CBD during endoscopic retrograde cholangiopancreatography, which revealed a tight stricture, which could not be bypassed using several guide wires and upstream dilation, and intraductal stones in the right hepatic duct. The duodenoscope was therefore replaced by a nasogastroscope (GIF-N180, Olympus) introduced with a 50 cm overtube for stability, to allow visualization of the site of stenosis and removal of the stone in the right hepatic duct ([Fig. 2]). A 6 mm polyp (Paris 0 – 1 sp) ([Fig. 3]) was visualized below the stricture and was removed using a diathermy snare (SD-221L-25, Olympus) ([Fig. 4]). This was followed by several targeted biopsies of the biliary stricture. Scopes were exchanged over a 0.035 Jagwire to dilate the stricture using a 6 mm × 4 cm Hurricane balloon, to extract pus and stones, and to place a 7-Fr plastic biliary stent. Histology showed no malignant cells, but revealed an inflammatory infiltrate in the biopsies and a fibroinflammatory polyp. During follow-up that lasted almost two years, the patient’s progress was favorable, the stent was left in place for more than one year, and he experienced no recurrent cholangitis.

Fig. 1 Abdominal computed tomography scan showing the dilated right intrahepatic ducts with intraductal stones.

Fig. 2 Fluoroscopy showing the position of the nasogastroscope and the biopsy forceps in the right hepatic duct.

Fig. 3 Cholangioscopic view of the polyp below the duct stricture.

Fig. 4 Cholangioscopic view of the post-polypectomy site.

Discussion

This case report illustrates the feasibility of biliary intraductal polypectomy during cholangioscopy performed with a nasogastroscope.

Abbreviations

CBD: common bile duct

Competing interests: None