A 51 yrs male patient was referred to us for the favor of endoscopic evaluation, EUS SOS ERC for suspected mass in the mid CBD region / gall bladder on other imaging studies with porta nodes and cholestatic symptoms. Patient has significant wt loss and now sr bil of 35 mg%

  • OGD scopy revealed a massively dilated esophagus with candidiasis, a very tight les
  • EUS scope passage was possible only after a 15 mm cre balloon dilatation
  • An irregular hypoechoic lesion in the region of upper CBD with few hypoechoic nodes in the porta
  • The mass seems to have invaded the gastroduodenal artery, no evidence of any hypoechoic lesions in the left lobe of liver or nodes in the mediastinum
  • EUS guided FNA was performed- cytological diagnosis was metastatic adenocarcinoma
  • Selective cannulation of CBD, cholangiogram showed bismuth type 1 stricture with communication of LT and RT ductal system
  • Biliary brushing was taken from the stricture- was inconclusive on cytology
  • A self expandable uncovered metal stent (10.0 cms) was then placed into the LT ductal system

Take Home Message :  As you can see in this patient who turned out to be advanced metastatic gall bladder cancer with multiple nodes leading to obstructive jaundice as well as secondary achalasia cardia. Now that balloon dilatation followed by EUS guided FNA from the nodal mass allowed us final tissue diagnosis of metastatic adenocarcinoma (gall bladder origin). Definitive palliation of severe cholestatic symptoms was achieved with ERCP and Metal Biliary Stenting. Surgical resection was ruled out due to metastatic disease process. Hence, any patient with suspected malignant obstructive jaundice a combination of EUS and ERCP will provide the most optimal diagnosis and effective palliation.

1. A massively dilated esophagus with candidiasis

2. Tight les seen on retroflexion

3. Balloon dilatation of les performed to facilitate EUS and ERCP

Aug4

4. An irregular hypoechoic lesion in the region of upper  CBD / gall bladder

Aug5

5. EUS guided FNA was  performed

Aug6

6. Selective cannulation of CBD

Aug7

7. Cholangiogram showed bismuth type 1 stricture with communication of LT and RT ductal system

Aug8

8. A self expandable uncovered metal stent (10.0 cm) was then placed into the LT ductal system