A case of endoscopic ultrasonography-guided choledochoduodenostomy for malignant distal bile duct obstruction with upside-down stomach

Abstract

Figures

Computed tomography revealed a 35-mm tumor in the pancreatic head, and obstruction of the distal bile duct and duodenum by the tumor was suspected.

The patient also had a esophageal hiatal hernia of the upside-down stomach type, and almost all of her stomach had prolapsed into the thoracic cavity.

Schema of this case.

A forward-viewing scope was advanced to the duodenum, and a stiff-type guidewire was advanced to the jejunum. The guidewire was left in place, and the endoscope was removed while the upside-down stomach loop was released.

A convex endoscope was successfully maneuvered around it to the duodenum. Thereafter, EUS-CDS was performed, and a covered self-expanding metal stent was placed successfully.

Full text

Endoscopic ultrasonography-guided biliary drainage (EUS-BD) is increasingly being used as a drainage technique in cases where endoscopic retrograde cholangiopancreatography (ERCP) cannot be performed. However, in patients with a massive esophageal hiatal hernia, this poses a risk of mediastinitis due to thoracic puncture. Upside-down stomach, first described in 1926 as type IV diaphragmatic hiatal hernia, is a rare condition in which a large portion of the stomach migrates into the thoracic cavity due to organoaxial rotation 1 . There have been reports of ERCP in patients with upside-down stomach 2 3 but none of EUS-BD. This is the first report of EUS-BD for distal bile duct obstruction in a patient with pancreatic head cancer and upside-down stomach.

An 84-year-old woman presented to our hospital with the chief complaint of weight loss. Computed tomography revealed a 35-mm tumor in the pancreatic head, and obstruction of the distal bile duct and duodenum by the tumor was suspected ( Fig. 1 ). The patient also had an esophageal hiatal hernia of the upside-down stomach type, and almost all of her stomach had prolapsed into the thoracic cavity ( Fig. 2 , Fig. 3 ). We decided to attempt endoscopic ultrasonography-guided choledochoduodenostomy (EUS-CDS) along with duodenal stent placement in the papillary region.

Computed tomography revealed a 35-mm tumor in the pancreatic head, and obstruction of the distal bile duct and duodenum by the tumor was suspected.

The patient also had a esophageal hiatal hernia of the upside-down stomach type, and almost all of her stomach had prolapsed into the thoracic cavity.

Schema of this case.

A forward-viewing scope was advanced to the duodenum, and a stiff-type guidewire was advanced to the jejunum ( Fig. 4 ). The guidewire was left in place, and the endoscope was removed while the loop for the upside-down stomach was released. A convex endoscope (UCT-260; Olympus, Tokyo, Japan) was then advanced over the wire to the esophagogastric junction. The contrast catheter was advanced, and the endoscope was successfully maneuvered around it to the duodenum. Thereafter, EUS-CDS was performed, and a covered self-expanding metal stent (ZEO STENT, 8 × 60 mm; Zeon Medical Inc., Tokyo, Japan) was placed successfully ( Video 1 , Fig. 5 ). This case demonstrates that EUS-BD can be safely performed for malignant distal bile duct obstruction with upside-down stomach if EUS-CDS is used.

A forward-viewing scope was advanced to the duodenum, and a stiff-type guidewire was advanced to the jejunum. The guidewire was left in place, and the endoscope was removed while the upside-down stomach loop was released.

A convex endoscope was successfully maneuvered around it to the duodenum. Thereafter, EUS-CDS was performed, and a covered self-expanding metal stent was placed successfully.

Endoscopic ultrasonography-guided choledochoduodenostomy for malignant distal bile duct obstruction with upside-down stomach.Video 1

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