C0469 - ERCP via Gastrostomy: A Work Around for Esophageal Stricture or Obstruction

Savan Kothadia, MD¹, May Min, MD², Fadlallah Habr, MD³, Sarah M. Hyder, MD, MBA^4
1Warren Alpert Medical School of Brown University , Providence, RI; ²Brown University, Providence, RI; ³Warren Alpert Medical School of Brown University, East Providence, RI; ⁴Lifespan Physician Group - Brown University, East Providence, RI

Introduction: In the setting of biliary obstruction, endoscopic retrograde cholangiopancreatography (ERCP) can be a life-saving intervention. Most often performed via the trans-oral approach, there are indications of ERCP via gastrostomy (GERCP), largely for patients with altered anatomy from Roux-en-Y gastric bypass surgery. Few reports exist regarding GERCP in the setting of esophageal obstruction or stricture. We present a patient with complete esophageal obstruction with subsequent percutaneous gastrostomy (PEG) tube requiring GERCP with a pediatric duodenoscope for acute management of choledocholithiasis.

Case Description/Methods: An 84-year-old female with history of a severe benign esophageal stricture refractory to serial dilations, esophageal stenting, and ultimately requiring 20 Fr PEG placement presented with back pain after a mechanical fall. Computed-tomography abdomen/pelvis: intra- and extra-hepatic biliary ductal dilatation with an 8 mm density in the distal common bile duct and a distended gallbladder. Labs: AST/ALT 68/89 IU/L, alkaline phosphatase 610 IU/L, and total bilirubin 2.7 mg. Magnetic resonance cholangiopancreatography confirmed choledocholithiasis. Endoscopic management was the only viable option due to poor surgical candidacy. ERCP via a trans-oral approach was attempted, but the esophageal stricture was completely stenosed, precluding passage of a 0.035 inch guidewire (Image A). The external PEG tube was removed and the gastrostomy stoma was dilated using a 12mm biliary balloon dilator under fluoroscopic guidance (Image B). An Olympus PJF-160 7.5mm diameter duodenoscope was passed through the stoma into the duodenum and the bile duct was cannulated. Fluoroscopy revealed 15mm duct dilation with a 10mm distal filling defect. Stone removal was accomplished via sphincterotomy and balloon, dilation-assisted-stone extraction (Image C). A 20 Fr externally replaceable PEG tube was placed at the stoma site at the end of the procedure.

Discussion: This case demonstrates an alternative approach to an arduous ERCP in a patient with a severe esophageal stricture which was not amenable to dilation or esophageal stenting. GERCP requires extra vigilance due to technical challenges related to positioning and thermal injury risk with a small caliber scope tip, but can serve as another option in an interventional endoscopist’s arsenal for managing biliary disease in patients with esophageal strictures.



Disclosures:


Savan Kothadia, MD¹, May Min, MD², Fadlallah Habr, MD³, Sarah M. Hyder, MD, MBA⁴. C0469 - ERCP via Gastrostomy: A Work Around for Esophageal Stricture or Obstruction, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.