US Quiz of the Month – Junho 2024

Case Report

We present a case of a 58-year-old female patient with stage IV pancreatic adenocarcinoma, currently undergoing palliative chemotherapy.

During a follow-up, she presented with jaundice and pruritus, with no pain or fever.  Laboratory tests revealed cholestasis (AST 465 U/L, ALT 261 U/L, alkaline phosphatase 336 U/L, and GGT 925 U/L), hyperbilirubinemia (total bilirubin 7.02 mg/dL and direct bilirubin 5.78 mg/dL) and normal CRP and leukocytes. Abdominal ultrasound showed common bile duct dilation (CBD), 10 mm, due to pancreatic head lesion with approximately 41 mm.

An attempt was made for an ERCP, however CBD cannulation was not possible.


What should be the next approach?

Patient was immediately submitted to an endoscopic ultrasound and biliary drainage via cholecystogastrostomy as a rescue technique, using a lumen apposing stent (Video 1.).

Video 1. Endoscopic ultrasound-guided cholecystogastrostomy (EUS-GB), using a lumen apposing stent.

The procedure was successful, resulting in abundant drainage of stagnant bile. The patient remained clinically stable during the hospitalization period with a decreasing bilirubin and was discharged on the next day.


ERCP is the first-line approach in palliation of malignant bile duct obstruction. When it fails, other endoscopic methods may be considered.

Cholecystogastrostomy is increasingly being described as a rescue technique for biliary drainage – especially when CBD doesn’t achieve 14 mm to perform a choledochoduodenostomy or intrahepatic dilation is less than 5 mm precluding an hepaticoduodenostomy – with high rates of technical and clinical success. Additionally, cholecystogastrostomy may prevent acute cholecystitis in patients with enlarged gallbladder due to pancreatic head neoplasia (Courvoisier syndrome) [1-4].


  1. Kamal F, Khan MA, Lee-Smith W, Sharma S, Acharya A, Farooq U, Aziz M, Kouanda A, Dai SC, Munroe CA, Arain M, Adler DG. Efficacy and safety of EUS-guided gallbladder drainage for rescue treatment of malignant biliary obstruction: A systematic review and meta-analysis. Endosc Ultrasound. 2023 Jan-Feb;12(1):8-15.
  2. Binda C, Anderloni A, Fugazza A, Amato A, de Nucci G, Redaelli A, Di Mitri R, Cugia L, Pollino V, Macchiarelli R, Mangiavillano B, Forti E, Brancaccio ML, Badas R, Maida M, Sinagra E, Repici A, Fabbri C, Tarantino I. EUS-guided gallbladder drainage using a lumen-apposing metal stent as rescue treatment for malignant distal biliary obstruction: a large multicenter experience. Gastrointest Endosc 2023; 98: 765-773.
  3. Fugazza A, Khalaf K, Pawlak KM, Spadaccini M, Colombo M, Andreozzi M, Giacchetto M, Carrara S, Ferrari C, Binda C, Mangiavillano B, Anderloni A, Repici A. Use of endoscopic ultrasound-guided gallbladder drainage as a rescue approach in cases of unsuccessful biliary drainage. World J Gastroenterol. 2024 Jan 7;30(1):70-78. doi: 10.3748/wjg.v30.i1.70. PMID: 38293324; PMCID: PMC10823897.
  4. Robles-Medranda C, Oleas R, Puga-Tejada M, Alcivar-Vasquez J, Del Valle R, Olmos J, Arevalo-Mora M, Egas-Izquierdo M, Tabacelia D, Baquerizo-Burgos J, Pitanga-Lukashok H. Prophylactic EUS-guided gallbladder drainage prevents acute cholecystitis in patients with malignant biliary obstruction and cystic duct orifice involvement: a randomized trial (with video). Gastrointest Endosc. 2023 Mar;97(3):445-453. doi: 10.1016/j.gie.2022.10.037. Epub 2022 Nov 1. PMID: 36328209.


Ana Rita C. Silva1, Nuno Nunes1, Francisca Côrte-Real1, Vera Costa Santos1, Maria Antónia Duarte1.

  1. Gastroenterology Department, Hospital do Divino Esprito Santo de Ponta Delgada, EPER.