Post written by Shosuke Hosaka, MD, from the Department of Gastroenterology, Chiba-nishi General Hospital, Matsudo, Chiba, Japan, and the Department of Gastroenterology and Gastrointestinal Endoscopy, Tokyo Metropolitan Geriatric Medical Center, Tokyo, Japan.

Endoscopic procedures such as ERCP and EUS are making significant contributions to the diagnosis and treatment of disorders in the biliopancreatic system in clinical practice. Endoscopic treatment has been regarded as a reliable and less invasive alternative to surgical treatment for diseases such as common bile duct stones and pancreatic stones.

However, duodenoscope insertion to approach the duodenal papilla is mandatory to perform these procedures.

We introduce a case with a conventional but difficult treatment for cholangitis because of a duodenal ulcer-induced stricture. The duodenoscope for the endoscopic treatment could not be inserted into the duodenal papilla because of the duodenal bulb deformity caused by duodenal ulcers.

Other treatment options for cholangitis include surgery or EUS with bile duct drainage. However, these options seemed infeasible for this high-risk patient, considering his age (90 years old) and comorbidities.

Therefore, we decided to crush and remove the stones, which were incidentally found through the duodenal ulcer, as a relatively less invasive treatment to improve symptoms.

A balloon catheter, a basket catheter, and a catheter to crush are used after incision or dilation of the duodenal papilla as a treatment method for common bile duct stones. However, electrohydraulic lithotripsy (EHL) has been reported as useful before stone removal in the case of a very hard stone that the catheter cannot crush.

This crushing method is advantageous because it can be applied under direct vision using a 1.9F ultrathin probe. Hence, we used this device to treat pancreatic stones that can be directly observed through the duodenal ulcer.

The pancreatic stone was successfully crushed and removed, but the bile duct could not be drained. EUS-guided bile drainage and self-expandable metal stent insertion for duodenal stenosis were required to improve symptoms, although EHL was an effective and safe treatment for pancreatic stone removal, as demonstrated in this special case.

In conclusion, this presentation aimed to guide treatment methods for difficult pancreatic stone cases.

Bile duct stricture because of the pancreatic duct stones. A, Coronal image. B, Axial image.

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