A 68 year old male patient, with history of renal transplant under oral imunosuppressive therapy (Everolimus 0,75 mg, Prednisolone 2,5 mg, MMF 1000 mg) and chronic hepatitis B virus infection under lamivudine, was admitted to our hospital with jaundice, coluria and acolia since the previous week.
Laboratory workup revealed normocytic anemia, hepatic lysis and colestasis pattern (AST 480 UI/l, ALT 536 UI/l, AP 303 UI/l, GGT 2652 UI/l), with conjugated hyperbilirubinemia (total bilirubin of 6,7 mg/dL, increasing up to a maximum of 29,2 mg/dL). The abdominal ultrasound showed intra-hepatic bile duct (IHBD) dilatation.
The patient was submitted to abdominal Computed Tomography (CT) and Magnetic Resonance Cholangiopancreatography (MRCP), which revealed a regularly shaped severe dilatation of the IHBD and of the Common Bile Duct (CBD), associated to a mild dilatation of the Pancreatic Duct (PD) (Figure 1).
Figure 1. A. Abdominal CT coronal slice; B. Abdominal MRI T1-wheighted sequence; C. MRCP.
After two unsuccessful attempts of biliary cannulation through Endoscopic Retrograde Cholangiopancreatography (ERCP), even after pre-cut, the rendez-vous technique was considered.
EUS and the rendez-vous technique
EUS identified a 20mm dilatation of the CBD, followed by an abrupt peri-ampullar stop caused by a 12mm hypoecoid lesion (Figure 2A and 2B). EUS-guided anterograde CBD canulation was achieved using a 19G needle (Cook ® Echotip ultra HD-A) through the second portion of the duodenum, proximal to the ampulla. A 0,035mm guide-wire was then placed in the CBD and inserted in the duodenum anterogradly (Figure 2C).
Figure 2. A. Dilatated CBD, whithout parietal alterations; B. 12mm Peri-ampullar hypoecoid lesion; C. CBD anterograde access using a 19G needle through the second portion of the duodenum.
ERCP biliary canulation was achieved using the EUS-placed guide-wire, followed by sphincterotomy and plastic biliary stent (10Fr, 7cm) placement, with excellent drainage (Figure 3).
Figure 3. A. EUS-guided placement of the guide-wire in the CBD; B. Biliary canulation by ERCP;
C. CBD and IHBD dilatation followed by an abrupt peri-ampular stop; Sphincterotomy, D. Plastic biliary stent.
Conventional biopsies were compatible with Adenocarcinoma of the Ampulla.
In patients with obstructive jaundice in which ERCP is unsuccessful, Endoscopic Ultrasound-guided Biliary Drainage (EUS-BD) is a less invasive technique when compared to the alternative approaches, namely Percutaneous Trans-hepatic Biliary Drainage (PTBD) or surgical procedures. Successful biliary drainage using this approach is attained in 73 to 97% of cases, allowing a physiological drainage with lower complication rates, using a single procedure 1-3.
The approach to the biliary tree can be achieved through the duodenum, with direct access to the CBD, or through the stomach, with access to the left hepatic duct 2, 3. EUS-BD can be divided into three different techniques: EUS-rendez-vous technique; EUS-guided transluminal biliary drainage; EUS-guided anterograde approach 1, 4.
Reported complications for these techniques vary from 4 to 21%, with pneumoperitoneum and biliary leak being the most frequent. The rendez-vous technique shows lower complication rates, when compared with the others approaches, probably because of its more physiological drainage2.
In this case, the redez-vous technique allowed the CBD drainage and the diagnosis of a peri-ampulary lesion. The use of a 19G needle was feasible and safe, allowing the insertion of a 0,035mm guide-wire. With its safe and minimally invasive profile, this technique is becoming the first-line approach when ERCP is unsuccessful.
1- Iwashita t., Doi S., Yasuda I., Endoscopic ultrasound-guided biliary drainage. A review; Clin J gastroenterol 2014;7:94-102
2- Chavalitdhamrong D., Draganov P.; Endoscopic ultrasond-guided biliary drainage, World Journal of Gastrenterology 2012; 1:491-497
3- Giovannini M, Boris E, EUS-Guided Biliary Drainage , Gastroenterology Research and Practice 2012; 348719 1-5
4- Gupta K, Mallery S, Hunter D, Freeman ML. Endoscopic ultrasound and percutaneous access for endoscopic biliary and pancreatic drainage after initially failed ERCP. Rev Gastroentrol Disord 2007; 7: 22-37.
Maria Ana Túlio1, Pedro Pinto-Marques2, Tiago Bana-Costa 1,2, David Serra2, Leopoldo Matos1
1- Department of Gastroenterology, Centro Hospitalar Lisboa Ocidental, Lisbon
2- Department of Gastroenterology, Hospital da Luz, Lisbon