Gabriel D. Lang, MD, from the Division of Gastroenterology, Washington University, Saint Louis, Missouri, presents this video case.

A 67-year-old female with locally advanced duodenal adenocarcinoma with previous metal biliary and enteral stents presented with jaundice. The cholangiogram demonstrated a complete obstruction at the proximal end of the stent. Multiple attempts to advance a variety of wires past the level of obstruction under fluoroscopic guidance were unsuccessful. A direct per-oral cholangioscope was then inserted into the bile duct, where a punctate area of bile staining was noted. Under direct endoscopic visualization, this area was targeted with the guidewire, the level of obstruction was bypassed, and a new metal biliary stent placed.

Cholangioscopy affords the endoscopist direct visualization of the bile duct and an alternative method to manage difficult biliary strictures. When a completely obstructed bile duct is encountered and traditional ERCP maneuvers fail, one can attempt EUS-guided biliary access versus percutaneous biliary drainage (PBD). In this case, cholangioscopy assisted deep bile duct cannulation prevented our patient from undergoing percutaneous biliary drainage, which is associated with increased risk of complications and increased length of hospital stay.

Figure 1: Chloangiogram demonstrating a completely obstructed bile duct.

In this unique case, cholangioscopy aided the endoscopist in traversing a tight stricture when EUS-guided biliary drainage would have been challenging secondary to the previously placed metal and biliary stents. This novel use of cholangioscopy should be considered when traditional ERCP maneuvers under fluoroscopic guidance are unsuccessful.

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