Post written by Sooraj Tejaswi, MD, MSPH, from UC Davis School of Medicine, Sacramento, California, USA.

We describe a multidisciplinary approach to obstructive jaundice due to 2 concurrent etiologies.

A 75-year-old man was transferred from an outside hospital for unresolving jaundice and elevated CA 19-9, despite a functioning percutaneous biliary drain (PBD) placed for biliary decompression of an abrupt cutoff in the common bile duct at the entrance of a large type IV hiatal hernia. He developed severe necrotizing pancreatitis around the tail of the pancreas after the PBD. 

Cholangiocarcinoma was one of the differential diagnoses. ERCP was not undertaken because of his complex anatomy and necrotizing pancreatitis. Instead, we undertook single-session percutaneous cholangioscopy with the novel short cholangioscope. This revealed a near-circumferential mass with tumor vessels in the common hepatic duct. Cholangioscope-directed biopsies revealed moderately differentiate adenocarcinoma. Downstream to the tumor was a high-grade, fibrotic-appearing biliary stricture due to traction from the large hiatal hernia, causing extrinsic compression.

Unfortunately, peritoneal spread was detected during laparotomy performed after neoadjuvant chemotherapy. The clinical course was complicated by recurrent bouts of cholangitis, and ultimately the patient chose comfort care and passed away. 

It was important to showcase this video because it demonstrates diagnostic utility of the novel short percutaneous cholangioscope. Second, this case describes the technique of same-session percutaneous cholangioscopy during the index procedure, instead of the usual technique of allowing 4-6 weeks for the percutaneous tract to mature before undertaking percutaneous cholangioscopy. It is vital to expedite a time-sensitive diagnosis such as cholangiocarcinoma in order to target a curative resection/liver transplant.

Third, this case highlights the need for being vigilant to the possibility of additional diagnoses to explain a clinical finding. Our patient had obstructive jaundice due to the large type IV paraesophageal hernia, but also due to coexisting cholangiocarcinoma.  

Finally, this case highlights the benefits of early collaboration of the surgery, endoscopy, and interventional radiology services in choosing the right type of tools and techniques for the clinical situation at-hand. Attempting and failing ERCP in complicated gastrointestinal anatomy could lead to diagnostic delays while exposing the patient to the attendant risks of ERCP.  

Single-session percutaneous cholangioscopy with the novel short cholangioscope can be performed during the index procedure. The technique we describe is very useful when faced with complicated/surgically altered anatomies, which may preclude ERCP or increase the probability of failed ERCP.

When in doubt, it may be best to proceed with percutaneous cholangioscopy instead of risking a failed ERCP, its attendant risks, and the avoidable delay in patient care. This is especially applicable in case of time-sensitive conditions such as malignancy. It is important to leave the percutaneous drain in place for 6-8 weeks after the procedure to prevent the risk of bile leak.

CT image showing a large paraesophageal hernia containing
stomach and transverse colon (white arrow).

Read the full article online.

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