Endoscopy Café Episode 4 - 10/18/2024
Presenter:
Idrees Suliman, MD
Advanced Endoscopy Fellow
Harbor UCLA Medical Center, Torrance, CA, US
A 41-year-old male presented to an outside hospital with acute pancreatitis complicated by the development of walled-off necrosis. He presented one month later with abdominal pain and post prandial nausea vomiting, and difficulties with oral tolerance. Laboratory evaluation did not suggest acute infection. CT scan showed a 13.6 x 20 x 11.5cm collection centered at the boy of the pancreas. Upon review of the images there appeared to be a large vessel within the walled off necrosis. Esophagogastroduodenoscopy (EGD) confirmed extrinsic compression of the stomach and duodenum to match the patient’s oral intolerance.
After multidisciplinary discussion with surgery, a Lumen Apposing Metal Stent (LAMS) measuring 15mm x 10mm was placed in a trans gastric fashion to achieve drainage. In light of ongoing fever and symptoms EGD was undertaken two days after the index procedure with placement of a double pig-tail plastic stent through the LAMS. He remained admitted to the hospital due to ongoing abdominal pain and fevers.
Approximately one week after LAMS procedure it was noted that the hemoglobin had gradually trended downward to 6.5g/dL from 11.8g/dL on admission. There was no overt evidence of GI bleeding and CTA showed no active hemorrhage. Repeat EGD at this time showed obstructed LAMS from hemorrhage into the cyst lumen. After multidisciplinary discussion, repeat EGD with clot clearance and necrosectomy was performed with technical success. LAMS was subsequently removed successfully two months after initial placement.
Post operatively, chylous ascites and pleural effusion have developed. This has been refractory to medium chain fatty acid diet, TPN with octreotide, and repeat paracentesis. Lymphangiogram did not identify any targets for intervention.
Discussion Questions:
Can endoscopic drainage of WON be undertaken when they contain blood vessels? Are there any changes in approach?
In the setting of hemorrhage post-LAMS placement, what is the approach?
What is the treatment of chylous ascites?
Expert Comments:
In WON that contain a blood vessels IR embolization should be considered only if a pseudoaneurysm is present. Placement of plastic pigtail stents with these collections could theoretically act as a barrier to protect the blood vessel from the LAMS.
Hemorrhage is a known post LAMS complication and can be present in the absence of overt GI hemorrhage. Treatment should include input from surgery, interventional radiology and gastroenterology. IR embolization is helpful if there is suggestion of an arterial component of hemorrhage.
Chylous ascites is treated with a diet high in medium chain fatty acids. Should this not be effective, a trial of octreotide with NPO/TPN can be undertaken. Lymphangiogram may be helpful in identifying targets for intervention. Experts felt that the above interventions are likely to succeed eventually, but symptom improvement might require watchful waiting.
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Endoscopy Café Case #1 - 10/9/2023
Presenter:
Hawwa Alao, MD
Advanced Endoscopy Fellow
Harbor UCLA Medical Center, Torrance CA, US
31 y/o male with ulcerative colitis and presumed primary sclerosing cholangitis (PSC) presented with RUQ pain, chills, vomiting, and abnormal hepatic panel. CT abdomen and pelvis with contrast showed cholelithiasis, distended gallbladder with pericholecystic fluid, and decreased enhancement of the gallbladder wall, concerning for acute cholecystitis with gallbladder wall ischemia consistent with gangrenous/hemorrhagic cholecystitis. Moderate to severe intrahepatic biliary ductal dilatation, hepatomegaly, and mildly nodular liver, suggestive of fibrofatty cirrhosis were seen. There was splenomegaly with splenic and paraesophageal varices, consistent with portal hypertension.
Initial labs revealed WBC 19.7 ,Alk phos-515 U/L, ALT- 91 U/L, AST- 69 U/L, T. Bili- 2.2 mg/dL, D. Bili- 1.3 mg/dL, Alb- 3 g/dL, PT-15.7. Chronic liver disease panel including autoimmune markers were negative and IgG4 levels were normal.
The patient had an emergent laparoscopic cholecystectomy for acute gangrenous cholecystitis with intra-operative cholangiogram showing bile duct stones. Subsequent intraoperative ERCP was performed with removal of 3 pigmented stones and placement of a biliary stent. Cholestatic hepatitis worsened post-operatively (Labs showed Alk Phos- 945 U/L, ALT- 156 U/L, AST-141 U/L, T. Bili-6 mg/dL, D. Bili-3.4 mg/dL). Repeat endoscopic exam showed 4 columns of < 5mm distal esophageal varices. EUS showed multiple collateral vessels around the portal confluence and turbulent anterograde flow in the portal vein consistent with portal HTN. ERCP cholangiogram revealed filling defects in the common bile duct and the right posterior hepatic duct. Multiple intrahepatic pigmented stones were removed with a single-operator peroral cholangioscope/EHL (SpyGlass, Boston Scientific) over several sessions with ductal clearance achieved.
Discussion Questions:
Are the findings consistent with PSC?
How would you manage this patient moving forward?
Given portal HTN findings, would you evaluate this further? If yes, how?
Expert Comments:
The expert panel concluded that the cholangiograms were atypical for PSC and presentation more consistent with recurrent pyogenic cholangitis as opposed to PSC. Chronic intrahepatic stone disease might have led to secondary cirrhosis and subsequent portal HTN. The patient had adequate imaging and endoscopic evidence of cirrhosis despite a normal platelet count and a liver biopsy or endoscopic portal pressure measurements were not warranted. The panel agreed that repeat ERCP-cholangioscopy was necessary to remove the large stone burden to improve cholestatic hepatitis and achieve ductal clearance.
Endoscopy Café Case #2 - 10/09/2023
Presenter:
Worapoth Yingyongthawat, MD
Advanced Endoscopy Fellow
Siriraj Hospital, Bangkok, Thailand
A 62-year-old woman presented with 4 weeks of progressive jaundice, dull epigastric abdominal pain, and 4 kg weight loss. Laboratory analysis showed ALT 46 U/L, AST 58 U/L, ALP 248 U/L, total bilirubin 14 umol/L, direct bilirubin 13 umol/L, CA19-9 was 161 U/mL.
CT abdomen and pelvis demonstrated 4.5 cm circumferential wall thickening with luminal narrowing along the common bile duct, common hepatic duct, and hepatic hilar region causing intrahepatic dilatation, concerning for periductal infiltrating type cholangiocarcinoma.
Based on the clinical presentation and the imaging, the preoperative diagnosis was type IIIA hilar cholangiocarcinoma Bismuth-Corlette classification. Two options for surgical management depending on the extent of the disease were extended right hepatectomy with pancreaticoduodenectomy and right trisectionectomy with pancreaticoduodenectomy. Preoperative biliary drainage was recommended. ERCP with direct single-operator peroral cholangioscopy (SpyGlass, Boston Scientific) revealed diffuse erythematous, edematous bile duct wall and polypoid protrusion with bile duct luminal narrowing extending from hepatic hilum to distal common bile duct. The cholangioscope could not be advanced above the stricture. Biopsies of the stricture were obtained. A transpapillary biliary stent was placed across the common bile duct stricture for biliary drainage with subsequent normalization of liver tests.
The pathology revealed moderately differentiated adenocarcinoma. Right portal vein embolization was performed to augment left lobe liver volume. The 3D CT liver volumetry after right portal vein embolization showed the future liver remnant of 45%, a minimal acceptable level for surgery. In the interim newly developed distant nodal metastasis with peritoneal carcinomatosis were found and bilateral side-by-side metal stents were placed for palliation. The patient passed away several months later from necrotizing pneumonia.
Discussion Questions:
Timing of direct cholangioscopy: at the index procedure vs. only when non-diagnostic brushings/biopsies from the initial procedure.
Role of cholangioscopy in the pre-operative planning to evaluate the extent of the disease
Role of portal vein embolization for augmentation of liver volume prior to surgical resection.
Expert Comments:
Experts uniformly agreed that it is preferable to have cholangioscopy performed at the index procedure if resources are available. They felt that cholangioscopy in addition to tissue sampling provides important information on the extent of disease and could be helpful for preoperative planning. EUS may be beneficial during the index procedure to define the extent of biliary involvement and to evaluate for metastasis not seen on imaging; such as peritoneal carcinomatosis. Portal vein embolization could be considered for liver volume optimization in challenging liver resection cases.
