Alright, good morning everyone. Our first case is that of possible biliary obstruction. We have an 88-year-old female with a history of rheumatoid arthritis and prior cholecystectomy who presents for postprandial abdominal pain that's been going on for about three months. She was admitted to another hospital for presumed biliary pancreatitis and as you can see her liver enzymes were elevated. Her bili was around 5.5, ASC, ALT, ALCFOS in the 200s to 300s range and her lipase was around 800. Her MRI and MRCP showed findings of a significantly dilated intra and extrahepatic bile duct as you can see in those images. There was no biliary obstruction noted, no evidence of stone or a stricture. An ERCP was attempted at another at that hospital but they weren't able to locate the papilla presumably because it was within a large perianfilary diverticulum. Her liver enzymes after the procedure actually started to downtrend but not normalize. Her liver enzymes are still a little mildly elevated. Incidentally, her CT and MRI also showed findings of a mildly dilated duodenum in the D1-D2 portion with a diverticulum as you can see in the CT there in the D3-D4 portion. She later admitted to symptoms of intermittent postprandial nausea, vomiting, abdominal distention, and a 35 pound weight loss in the past year. So our plan is to evaluate her endoscopically to figure out what's going on in her small intestine as well as perform EUS guided interventions as well as ERCP. Over to Dr. Khashab. Okay, thank you, Shruti. Can you still hear me? Yes. Okay, so let's focus on the EUS image to start with, please. So I'm using a linear echoendoscope, Olympus echoendoscope, and we are situated in the duodenal bulb and we can see here very dilated bile duct. This is about two centimeters and we see the cystic duct there, it's also dilated. We can follow the bile duct all the way down so we can see that this here is the pancreas duct and this here is the bile duct and we can follow it down and dilate it all the way. We don't see any filling defects, don't see stones, no structures, so this is all all the way down to the papilla. We looked with an EGD scope and duodenoscope when we were offline, there is no gastric outlet obstruction. So the radiologic finding, probably due to 35 pound weight loss, but basically her nausea, vomiting is not due to an SMA syndrome. So that's where we have to, you know, the chicken or the egg with the issue with the SMA, but if you can pass the scope easily that's not SMA syndrome, it's just a radiologic finding. So my working diagnosis here is that this patient has biliary symptoms, obstructive symptoms, and with postprandial pain and intermittent elevation in her LFTs and she got an episode of jaundice. So we see here the bile duct is very dilated and the intrahepatics, if you come back here and I'll show you the intrahepatics, not that impressive. So this is probably segment three here and we see the bile duct here is, this is about six millimeters centrally, but if you go a little bit more peripheral where we like to access the duct is probably here. This is five millimeters. Mild intrahepatic dilation, severe extrahepatic dilation, intra-ampullary diverticulum. So when I ask our experts here for advice, definitely challenging case. What do you guys advise? Well, we had talked offline before the course about the possibility of a cortical cyst. Honestly, looking at the MRI, there is a little more intrahepatic dilation than I would have expected. For the audience, cortical cysts usually have a marked extrahepatic and minimal to no intrahepatic ductal dilation. So an intrahepatic duct of six millimeters is still a decent size, even though you said it's kind of central. I think the one you're looking at is kind of peripheral. I didn't see a long common channel on the MRI and I didn't see that also under EUS, which would suggest a cortical cyst. And in somebody this age, I still think it's more likely some sort of obstructive process. Now the question would be, what would that obstruction be if you don't see anything on the EUS? You don't think there's a downstream obstruction, but her duodenal bulb is dilated on the MR, suggesting maybe there is a downstream element of obstruction that could cause some ductal dilation in and of itself. But I agree, it's a little bit of a confusing presentation. Yeah, and her bilirubin was five, you know, so she was jaundiced. Oh, no, no, no, I don't doubt it. I'm just wondering why we're not seeing more of a true obstructive process. Well, the fact that she presented with what sounds like biliary pancreatitis would suggest maybe she had sludge, but we don't see that. By the way, is her gallbladder in? I forgot to ask. So her gallbladder is out. Okay, so right. In this sense, you think that the combination of postcolistectomy dilation and the presence of diverticula in the second part of the duodenum can create the condition for obstruction or at least intermittent obstruction causing symptoms and blood test elevation? Yeah, I think that's a good point. Yeah, I mean, I agree. Usually, we see eight to ten millimeter ducts with post gallbladder. There's a huge diverticulum, but she has symptoms, so that's the only difference. And significant weight loss, and she got this episode of jaundice. So my plan is to access her biliary system transhepatically, get a cholangiogram, take it past the wire, see if we can do a rendezvous, and take it from there. A cholangiogram by itself may be helpful. A transhepatic approach is really safe because, you know, the hepatic parenchyma will tamponade the puncture side of the biliary tree, so I'm going to go with that route. We gave the patient antibiotics. The patient is on her back under general anesthesia. Can you please show us the fluoroscopy image side to side with the EOS image? We have a question. We have a technical question. Is there any limitation in terms of size of intrapartic duct to make sure you can puncture? Yeah, so the puncture, even if it's very small, getting cholangiogram, you can. Starting five millimeter, you can put a stent. This here is adequate for just passing wire, but also adequate for passing a stent. So it's not bad. As long as you can actually see an intrapartic duct, you can puncture it. The difficulty when they get extremely small is, of course, right now our equipment is either a wire or contrast, and if you're in a really small duct and they have respiratory, by the time you flush and get your wire ready, your needle can be out. So he's in, obviously, in an intrapartic nicely. So here, this is segment three, just under the left hepatic vein. Please tell us how you identify segment three. So here, I can't move now, but I will in a minute. So we're inside the duct, and very important that the scope is pointing towards the hylum. Show us, please, fluoroscopy live. Don't stop. So here, we're going to get a cholangiogram. So we're filling the ball duct there. Probably we can have a fluoro in a bigger picture. Yep. So now we can focus on fluoroscopy, please. Live. So saline after this. So I would like to fill the ball duct a little bit more. Megan, let's just breathing a little bit deep here. It's taking us. So this is what Todd was saying, is that if the duct is very small with the breathing, the needle will come in and out. So this is saline here. Take that picture, please, live, and give me a visit to live. Off. Okay. So, I mean, this is an impressive vial. It definitely looks like, you know, cystic dilation of the proximal part. So I definitely worry about that. So now I'm using an angle tip VisiGlide 2Y. So this has a very soft tip. Moinu, before you go ahead, there are two questions from the audience that I think are both very interesting. First, live, please. Yep. Go ahead. You think that there should be space before you go to U.S. cholangiogram to make a second attempt to ERCP just in case of failure and refer patients to an expert center? And the other one, SOD, sphincter audit dysfunction can be a cause of this situation? Yeah, they're great questions. You know, so the, I looked actually at an ERCP scope. The papilla is totally intra-diverticulum. So it would be very hard to manipulate your scope. You have to get the scope into the diverticulum. I think it's very difficult. With passing a wire and doing a rendezvous, you're going to basically change the direction of the papilla towards the duodenum. And then it makes it much easier. For SOD, you know, we don't talk about SOD type 2 or 3. We talk about type 1, which is dilated duct abnormal LFTs and biliary pain, which this patient has. So type 1 is true and it could be, yes. Can we mag please on the intrahepatics? But sphincter body doesn't usually give you a biliary ribbon of 5. It doesn't. It's usually the AST, ALT. So Mouen, I tend to go segment 2, preferably where it's above where you are now looking down rather than looking up. Can you comment on that? Because of the angulation? Yes. Well, yeah. Because of the, I think the pushability is a little bit better. But, you know, I can't, you know. Yeah. So same here. I like segment 2. So the advantage of segment 3 is for re-intervention. You know, segment 2 is very close to the junction. Re-intervention becomes difficult, but it's easier to access to the hilum now with the wire. The issue here, when I moved to segment 2, the ducts became very small. But now that you've injected, let's say, theoretically, you could have injected and filled them and then pulled back and stuck the higher one. So now what we are going to do is, so obviously difficult now to get the wire down because of the angulation, but I'm going to continue to try. Give me a live floor, please. So two points, Mouen. One, who's going to manipulate the guide wire? So you need an expert assistant or you do it yourself? Yeah. So here. The second point you're doing, you're doing a great job. So using the looping the tip of the guide wire to make a very safe advancement. Sorry, stop, stop, stop. So here, this is an angled tip and I basically just like wet my hand and rotated myself. And this is why I'm using an angled tip is to point it down towards the hilum. And imagine the scope is a little higher, you know, it's a scope a little higher that's segment 2. It's much easier to get down. Then without manipulating, it's going to go down towards the bottom. But here we needed some manipulation because we're going segment 3, just because segment 2, the ducts were not as dilated as I would like them to be. So now I want to see if I can pass the wire through the papilla. So this is where it becomes challenging with very dilated ducts because the wire tends to loop within the duct. You know, so, so we'll see if we can, if we can do that. Can you unmag please? Go ahead guys. Can you, can you focus on the distal part of the bile duct please? Yeah, real quick. One of the audience members asked the gauge of the needle. I presume you're using a 19 gauge and an 025 wire, right? Yeah, off. So this is, live please again. So what I'm going to do now, off, is, can you mag again, mag one, is exchange. So please prepare the the cap and we're going to exchange the wire. So the reason here, I want to manipulate the wire, but I want the needle, so I put the needle out. I don't want to manipulate the wire a lot with the needle in. You know, the wire can get caught on the tip of the needle. It's going to exchange and see if I can do a rendezvous. Yeah, okay. The other thing to point out, that's an excellent point. The other thing is what you find is the wire is much more rotatable and responsive when it's out of the needle, just free by itself, not constrained within the needle. You have a full control with the one-to-one movement. Whatever happens, you control. So here, one thing for the audience is, see here on EOS, I don't know if you have the EOS image, you want to have, you have, we want to have the wire, you know, and visible to you, because if the wire is not visible, your position changed and this can mess up your entire procedure. Then you can be pushing the wire and you're going to be looping it between the space, between the stomach and the echo endoscope. You don't want that. So you always want to have the wire in position, means your EOS scope is still where it is without any issue. So now what we did, we're putting the cap back because it just stabilizes the, can you please push the cap down all the way? If I need to look endoscopically insufflates. Remember, we haven't looked endoscopically. You don't want to do that at this time. So let's see if we can manipulate the wire live. Please don't stop. Can you come down a little bit here? Just show me the distal balda. Okay, good. So one thing we can do of course, is put a catheter down and the catheter will give, we give the wire some strength, some pushability. So we'll do that. Give me a four millimeter hurricane. So here's, I use a hurricane balloon for different reasons. One, it's a short wire system. So I have full control on the wire. It's not going to go anywhere. The tip of the balloon is very good for puncture through the gastric wall and through the capsule of the liver without cautery. So it helps. And then if I need to do a hepatogastrostomy, then I can dilate the tract and place a stent. So live please, Flora. Good. Off. So you see here, Flora, by EUS, the wire is still there. So here, importantly, when you see the wire, that's the puncture angle with the needle. So this tract, you already dilated a little bit with the needle itself. So if you go through the same tract, the balloon should go without a problem most of the time. Flora, please, live. That's really important for people that are considering doing EUS therapy, is to not look at the endoscopy, the traditional endoscopy, because when you do that, it uncouples from the echo view and you lose your angle. The angle you have of that puncture with the wire is the key mechanical advantage. So where you see things go wrong is when people start to back away and look and everything changes. So that's really important. I think Wayne is doing this very nicely. So the scope is always very stable, stationary. So you keep pressure on the scope in order to maintain the same position and not get back. Live. So here, I'm trying to push the balloon down a little bit more. It won't go. So I'm now trying to manipulate the wire. And it's not, if this doesn't go for a rendezvous, what I'll do is I'll put a hyparogastrostomy stent, which will serve as a port, you know, or access. You can change the wire. You can use a straight one. Now we can't, because this is a short wire system. Ah, this is a short wire system. Okay. So the balloon, if the balloon catheter goes down, that'll be really helpful. But you see here, what's happening here is I'm just pushing the off. Okay. So I think what I'm going to do here is dilate the track and place a fully covered hyparogastrostomy stent that will drain the bile duct and will serve as a port of entry. If there is a distal obstruction, I'm hoping that causing this whole issue, I'm hoping that the duct will decompress. If it doesn't decompress and stay this big, we're going to definitely have to discuss this with the hepatobiliary surgery, because I still worry about a colodocal cyst. This is a 21 millimeter duct. I mean, look, look at this common hepatic duct. It's humongous. Yeah. The only, my only, um, I'll take the other argument. She is 80 years old, right? Really healthy otherwise. Yeah, but they all look their age on the operating table, you know? Um, so, and if she hasn't developed a cholangiocarcinoma, uh, in 80 years with a colodocal cyst, what is the likelihood in her lifetime that she'll have it? Yeah. So let me ask you guys a question. So, uh, her postprandial pain, her postprandial pain, that's the issue, right? Like she, it's rather than the cholangioresque, I'm, I'm talking more about, she's just having low-grade cholangitis or stasis. That's, that's my point. But if you provide good drainage for her, if you have to leave stents in indefinitely, that's not a bad thing. Yeah. I mean, uh, you know, I can, like we do with pancreatic gastrostomies, you put a stent, you can just check on it once a year. And then, so this stent, okay, dilate at least to four, I'm going to dilate the tract to four millimeter and then open the 10-8 fully covered and then put a, uh, 10-8 fully covered stent and then, and then that's it. So, uh, so if, so I'm gonna dilate to four, we can bring you back to show you a stent placement. I think they are ready for you and, and the other room. So you see that the balloon went easily. I'm going to dilate just to four. So the stent, which is 8.5 French catheter, it should go very easily. Uh, and then we place the stent, we see her symptoms, we check her symptoms following, during follow-up, which we'll, we'll check on her biliary dilation during follow-up. If her symptoms resolve, then I think we're good. We have a technical point. Why dilation rather than using electrocautery to create the tract? Live. Yep. So, uh, you know, here we don't have a six French cystotome off dilate. Okay. Uh, so, and, and you saw that we don't need carotid, you know, anytime you use carotid, of course, uh, especially in a vascular organ, then like the liver is an issue. Uh, but first we don't have the six French and this, we figured out that this blunt catheter just works as well. This is great. Yeah. This is great demonstration, Dr. Gashab. We will go to Dr. Ginsberg from University of Pennsylvania. Thank you guys.

biliary obstruction

cholecystectomy

ERCP

EUS procedure

gastrostomy stent

follow-up