P0678 - Cholangiocarcinoma Obscured by a Large Paraesophageal Hernia Causing Traction Compression of the Common Hepatic Duct Ultimately Diagnosed With Percutaneous Cholangioscopy

Justin Louie, MD¹, Rex M. Pillai, MD¹, Thomas W. Loehfelm, MD, PhD², Sepideh Gholami, MD¹, Sooraj Tejaswi, MD, MSPH, FACG^3
1University of California Davis Medical Center, Sacramento, CA; ²UC Davis Health, Sacramento, CA; ³University of California Davis, Davis, CA

Introduction: This video demonstrates a unique case of biliary obstruction.

Case Description/Methods: A 75-year-old male presented to an outside hospital with painless jaundice. Abdominal CT and MRI showed severe intrahepatic biliary ductal dilation with an abrupt cutoff in the common bile duct at the entrance to a large type IV hiatal hernia containing the entire stomach and proximal duodenum. The proximal duodenum was being pulled into the hernia tightly leading to compression of the common bile duct. He underwent right sided internal/external biliary drain placement by interventional radiology. Following this he developed necrotizing pancreatitis likely due to traction of the pancreas into the paraesophageal hernia. He presented to us for further management. He had persistently elevated liver enzymes, as well as elevated CA 19-9, raising suspicion for an alternative diagnosis. Intraductal evaluation with ERCP was deferred due to his complex anatomy and necrotizing pancreatitis. In conjunction with interventional radiology, we performed a percutaneous cholangioscopy. This revealed a near-circumferential mass with tumor vessels in the common hepatic duct. Cholangioscopy-directed biopsies returned as moderately differentiated adenocarcinoma, leading to a diagnosis of Klatskin tumor (Bismuth-Corlette Type 1). Just distal to this mass was a 2.5 cm high-grade biliary stricture due to traction from the large hiatal hernia causing extrinsic compression. Due to persistent left sided biliary ductal dilation, we also completed percutaneous cholangioscopy of the left intrahepatic ducts, and did not see any additional abnormalities.

Discussion: We present the first case of a co-existing cholangiocarcinoma, complicating a very rare manifestation of type IV hiatal hernia. Obstructive jaundice due to abrupt tapering of the common bile duct at the hiatus of a type IV hiatal hernia is extremely rare. Pancreatitis secondary to obstruction of the pancreatic duct due to incarceration of the pancreas inside the hiatal hernia is also very rare. Definitive management requires surgical repair of the hiatal hernia, and is undertaken after decompression of the biliary obstruction and conservative management of pancreatitis. Biliary decompression is best done by percutaneous drainage, since ERCP is less likely to be successful due to the challenging anatomy and may worsen pre-existing pancreatitis. Surgery may need to be performed urgently if there is concern for bowel ischemia due to strangulation inside the hiatal hernia.


Figure: Cholangioscopy of mass with tumor vessel


Disclosures:
Justin Louie indicated no relevant financial relationships.
Rex Pillai indicated no relevant financial relationships.
Thomas Loehfelm indicated no relevant financial relationships.
Sepideh Gholami indicated no relevant financial relationships.
Sooraj Tejaswi indicated no relevant financial relationships.


Justin Louie, MD¹, Rex M. Pillai, MD¹, Thomas W. Loehfelm, MD, PhD², Sepideh Gholami, MD¹, Sooraj Tejaswi, MD, MSPH, FACG³. P0678 - Cholangiocarcinoma Obscured by a Large Paraesophageal Hernia Causing Traction Compression of the Common Hepatic Duct Ultimately Diagnosed With Percutaneous Cholangioscopy, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.