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When Might Endosonographic Decompression of Courvoisier’s Gallbladder Be Required With Palliative Metallic Biliary Stenting? A Case Series


Hammad, Tariq MD; Alastal, Yaseen MD; Bawany, Muhammad MD; Ali Khan, Muhammad MD; Ahmad, Usman MD; Alaradi, Osama MD; Nawras, Ali MD, FACG

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American Journal of Gastroenterology: October 2014 - Volume 109 - Issue - p S298
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Introduction: Metallic stents (MS) has been used as palliative drainage in malignant common bile duct (CBD) strictures. Cystic duct (CD) obstruction with resultant cholecystitis and empyema is a rare potential post metallic biliary stenting complication in specific high-risk situations. After encountering 2 incidences of post palliative metallic biliary stenting cholecystitis; we adopted the practice of endosonographic (EUS)-guided aspiration of gallbladder (GB) at the time biliary stenting in carefully selected patients. Here we report 3 patients where the distended GB was decompressed at the time of palliative stenting of CBD using EUS-guided fine needle aspiration (EUS-FNA).

Case Reports: Two patients with presumed stage 4 adenocarcinoma of the head of pancreas and 1 patient with stage 4 metastatic sacomatoid carcinoma of the lung to the pancreatic head presented with jaundice. In all patients, liver function test showed obstructive pattern. Abdominal CT showed a mass in the head of pancreas, biliary ductal dilatation (BDD), and massively distended GB. The patients were referred to our endoscopy unit for EUS-FNA confirmation of the diagnosis and for endoscopic retrograde cholangiopancreatography (ERCP) for potential palliative CBD stenting. EUS-FNA of the pancreatic masses was done. Onsite cytopathological exam confirmed malignancy. EUS again showed severely distended GB. The patients underwent ERCP, which showed either high-grade med or distal CBD strictures with significant extrahepatic BDD. Strictures were dilated and stented with partially covered self-expandable metallic biliary stents. CD take off was either at the level of covered part of the MS or not identified. Hence, EUS-guided decompression of the GB by FNA was performed at the end of the procedure without any complications.

Conclusion: Although GB decompression is not necessary for the vast majority of palliative metallic biliary stenting; it should be considered in subset of patients with high potential risk for post stenting cholecystitis (Figure 1). Further large studies are required to validate these observations.

Figure 1:
Algorithem showing when decompression of Courvoisier’s gallbladder is required with palliative metallic biliary stenting.
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