We present a case of a 44 y old woman with primary biliary and alcoholic cirrhosis who presented with RUQ pain and encephalopathy. Further evaluation revealed acute cholecystitis with VRE and Candida bacteremia.
She was not a candidate for laparoscopic cholecystectomy or radiologic cholecystostomy tube due to her decompensated cirrhosis, with a MELD score of 39. She was not a candidate for liver transplant due to continued alcohol abuse. Due to persistent bacteremia, the decision was made to place a gallbladder stent for decompression.
The side-viewing endoscope was passed into the duodenum with visualization of the major papilla. Cannulation of the bile duct was performed. During ERCP, her cystic duct could not be opacified by contrast through a sphincterotome or by an occlusion cholangiogram using a balloon catheter. We attempted to pass the 0.035 inch angled glidewire and the 0.035 inch Jagwire through the cannula. After several repeated attempts of unsuccessful cannulation, we removed the catheter.
A 10-French cholangioscope was then introduced into the bile duct over a Jagwire. We advanced the delivery catheter over the guidewire, up the extrahepatic biliary tree, under direct visualization with the fiberoptic probe. We visualized the right and left main hepatic ducts at their take-off from the bifurcation. The cholangioscope was slowly withdrawn from the bifurcation while closely examining the extrahepatic bile ducts. Cholangioscopy was used to attempt to locate the cystic duct take-off from the extrahepatic bile duct. The cystic duct was identified by direct visualization. We then maneuvered a 0.035 inch glidewire through the distal common bile duct and selectively cannulated the cystic duct using cholangioscopy.
The cholangioscope and fiberoptic probe were then removed and a tapered cannula was back-loaded over the wire. The cannula was used to help advance the wire from the cystic duct into the gallbladder under fluoroscopy. Once the wire was adequately advanced into the gallbladder, the wire was looped for further stability. We then injected contrast into the cystic duct and gallbladder to confirm wire placement, which confirmed our proper location. We then successfully placed a 5 French by 15 cm double-pigtail stent into the gallbladder. The gallbladder stent was then pushed out of the side-viewing endoscope to allow for the external pigtail to loop in the duodenum. Proper stent placement was confirmed in the gallbladder under fluoroscopy. The procedure was completed without complication.
There was initial improvement in the patient's mental status and leukocytosis after gallbladder stent placement. However, due to the patient's deterioration from hepatorenal syndrome, coagulopathy, and fungemia, the family elected to pursue comfort care one week later.
In summary, transduodenal gallbladder stents can be placed in patients with advanced cirrhosis for complicated cholelithiasis or acute cholecystitis as definitive treatment to decompress the gallbladder or as a bridge to liver transplant.
In conclusion, peroral cholangioscopy is a useful tool to assist in the placement of a gallbladder stent.
Jason R. Taylor, MD, University of Michigan
B. Joseph Elmunzer, MD, University of Michigan
Cyrus R. Piraka, MD, University of Michigan
Richard S. Kwon, MD, University of Michigan