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The Turkish Journal of Gastroenterology
2009, Volume 20, No 4, Page(s) 304-305
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LETTERS TO THE EDITOR
Bedside ERCP without fluoroscopy in a case with acute cholangitis and impaired general status
Ülkü SARITAŞ, Altuğ ŞENOL, Muharrem KESKİN
Department of Gastroenterology, Süleyman Demirel University, School of Medicine, Isparta
Introduction
To the Editor,
Endoscopic biliary drainage is an effective method to achieve biliary decompression in the management of patients with acute cholangitis (1-3). We discuss herein bedside endoscopic biliary stent insertion without fluoroscopy in a case with acute cholangitis and impaired general status in the intensive care unit.
A 75-year-old male patient was admitted to the intensive care unit due to jaundice and unconsciousness. On admission, he had an impaired general status, was unconscious, and the skin and mucosa were severely icteric. Laboratory findings were as follows: serum alkaline phosphatase (ALP) 713 U/L (normal: 0–270 U/L); γ-glutamyl transpeptidase (GGT) 517 U/L (normal: 5–61 U/L); alanine transaminase (ALT) 92 U/L (normal: 0–41 U/L); aspartate transaminase (AST) 124 U/L (normal: 0–37 U/L); total and direct bilirubin 29.22 mg/dl (normal: 0.01–1.00 mg/dl) and 19.49 mg/dl (normal: 0.1–0.3 mg/dl), respectively; hematocrit 32% (normal for male, 40-49%); leukocyte count 12,800/uL (normal: 4000-12000/uL); platelet count 410,000/uI (130,000-400,000/uI); prothrombin time (PT) 23.2 sec (normal: 10-14 sec); activated partial thromboplastin time (aPTT) 28.1 sec (normal: 29-45 sec); and international normalized ratio (INR) 2.1 (normal: 1-1.3). Abdominal ultrasound showed that the intrahepatic biliary tract was dilated; the common bile duct was measured as 20 mm at its widest part and a calculus of 12.5 mm diameter was found distally. Since the patient had the pentad of acute cholangitis (pain, fever, jaundice, hypotension, and oliguria), the picture was considered as severe; therefore, we decided to perform emergency endoscopic biliary drainage. Since the patient could not be mobilized to the radiology unit due to his impaired status, it was planned that he would undergo a bedside endoscopic biliary drainage without fluoroscopy. A side-view duodenoscope was inserted. After locating the major papilla, cannulation was performed with a standard catheter directed at the 11 o’clock position on the papilla or biliary axis with attempted deep cannulation of the bile duct. When the catheter was used for aspiration, bile flow confirmed correct cannulation of the common bile duct. The bile was observed to be dense and infected. We decided to insert a stent for biliary drainage. The papilla entrance was determined and a 7F Amsterdam type plastic stent, 8 cm in length and with lateral pores and flaps on both sides, was inserted. The next day, serum bilirubin level decreased. He was discharged as his general status had improved.
When compared with surgery under general anesthesia, the endoscopic retrograde cholangiopancreatography (ERCP) procedure has a lower mortality and morbidity (1-4). In routine practice, the ERCP procedure and biliary stenting are performed with fluoroscopy. However, in the intensive care unit, in patients with an impaired general status who cannot be transported to the endoscopy or radiology units and those with acute cholangitis for biliary obstruction, emergent bedside nasobiliary drainage (NBD) may be applied (1, 5-8). Although it would have been more adequate to do NBD to control bile drainage and to irrigate, it was thought that fixation of NBD would be difficult since the patient was agitated and unconscious; hence, NBD was abandoned. In addition, the patient was elderly and had severe comorbidities, so it was thought that stenting would provide both emergency endoscopic biliary drainage and prevent obstructive complications related with the calculi. Furthermore, stenting would not require a second ERCP for biliary drainage, while NBD would not remain too long after resolution of the cholangitis. In elderly people with such problems and where calculi cannot be extracted, biliary stenting is a treatment option. In the literature review, biliary stenting without fluoroscopy, guided by ultrasound, has been reported as case reports, but no cases have been reported of biliary stent insertion without the guidance of any imaging method.
In conclusion, in patients with impaired general status and those unfavorable for transport to the endoscopy room for ERCP, bedside NBD or stenting is beneficial if biliary decompression is obligatory. This case is original since, to our knowledge, there has been no other case report of bedside biliary stenting in the literature, and the procedure yields a successful result.
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  • Introduction
  • References
  • References
    1. Wang PH, Huang SP, Sun MS, et al. Urgent endoscopic nasobiliary drainage without fluoroscopic guidance: a useful treatment for critically ill patients with biliary obstruction. Gastrointest Endosc 2000; 52: 741-4.
    2. Lau JY, Chung SC, Leung JW, et al. Endoscopic drainage aborts endotoxemia in acute cholangitis. Br J Surg 1996; 83: 181-4.
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    6. Leung JW, Chung SC, Sung JJ, et al. Urgent endoscopic drainage for acute suppurative cholangitis. Lancet 1989; i: 1307-9.
    7. Lia XZ, Chang KK, Shin JS, et al. Endoscopic nasobiliary drainage for acute suppurative cholangitis: a sonographically guided method. Gastrointest Endosc 1993; 39: 174-6.
    8. Chawla YK, Sharma BC, Singh R, et al. Emergency endoscopic nasobiliary drainage without the aid of fluoroscopy. Indian J Gastroenterol 1993; 12: 97-8.
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  • Introduction
  • References
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