Single-session endoscopic ultrasound-guided gallbladder drainage and biopsy in pancreatic cancer, obstructive jaundice, and acute cholecystitis: A case report

Abstract

BACKGROUND

An 81-year-old patient presented to our center with pancreatic head cancer, obstructive jaundice, and acute cholecystitis. Due to duodenal tumor infiltration, both endoscopic retrograde cholangiopancreatography and endoscopic ultrasound (EUS)-guided choledochoduodenostomy were technically challenging.

CASE SUMMARY

An EUS-guided gallbladder drainage along with an EUS-guided fine needle biopsy were performed, resulting in a diagnosis of pancreatic cancer resolution of jaundice and improvement in acute cholecystitis, all in a safe and effective single endoscopic session.

CONCLUSION

This case demonstrated the successful use of EUS-guided gallbladder drainage and EUS-guided fine needle biopsy in a patient with pancreatic cancer invading the duodenal wall.

Key Words: Acute cholecystitis; Endoscopic ultrasound; Interventional procedures; Jaundice; Biliary obstruction; Fine-needle biopsy; Case report

Core Tip: The combination of endoscopic ultrasound (EUS)-guided fine needle biopsy and endoscopic retrograde cholangiopancreatography is well-documented in the literature. EUS-guided biliary drainage is an established alternative when endoscopic retrograde cholangiopancreatograph fails. EUS-guided gallbladder drainage is increasingly recognized as a valuable option for effective biliary decompression. When EUS-guided gallbladder drainage is used to alleviate jaundice, confirming cystic duct patency is essential to avoid suboptimal drainage. An 81-year-old patient with pancreatic head cancer, obstructive jaundice, and acute calculous cholecystitis had cystic duct patency successfully confirmed via EUS. This enabled a combined therapeutic approach that effectively resolved the cholecystitis and relieved the biliary obstruction.

INTRODUCTION

Pancreatic head cancer is frequently associated with obstructive jaundice due to the compression of the common bile duct by the tumor mass. In some cases this obstruction is compounded by acute cholecystitis, creating a complex clinical scenario[1]. Endoscopic ultrasound (EUS)-guided fine needle biopsy (FNB) is considered the gold standard for obtaining histological confirmation of pancreatic cancer[2,3]. A single-session EUS-FNB combined with endoscopic retrograde cholangiopancreatography (ERCP) is the optimal approach for managing patients with obstructive jaundice caused by a pancreatic mass as it allows for both simultaneous diagnosis and therapeutic intervention[4,5]. ERCP can be technically difficult, particularly in patients with duodenal tumor infiltration. When ERCP is unsuccessful, EUS-guided biliary drainage has emerged as a promising alternative to effectively reduce jaundice[6,7].

CASE PRESENTATION

Chief complaints

An 81-year-old female presented with progressive jaundice, right upper quadrant pain, and fever.

History of present illness

The patient had been experiencing nausea and upper abdominal pain for the prior 4 days that was accompanied by jaundice and fever.

History of past illness

The patient’s past medical history included diabetes.

Personal and family history

The patient’s personal and family history did not indicate any factors relevant to her current illness.

Physical examination

Upon physical examination the abdomen was tender to palpation in the upper right region. The patient appeared jaundiced and febrile.

Laboratory examinations

The results of the patient’s laboratory examination are as follows: Total bilirubin 5.1 mg/dL [normal < 1.2 mg/dL] (direct bilirubin 3.7 mg/dL); alkaline phosphatase 165 U/L (normal < 120 U/L); aspartate aminotransferase 182 U/L (normal < 48 U/L); alanine aminotransferase 155 U/L (normal < 40 U/L); C-reactive protein 15 mg/dL (normal < 0.5 mg/dL); carcinoembryonic antigen 7.3 ng/mL (normal < 5 ng/mL) and cancer antigen 19-9 > 500 U/mL (normal < 40 U/mL).

Imaging examinations

CT revealed a 31-mm mass in the head of the pancreas that had invaded the duodenum and the superior mesenteric artery. Additionally, gallbladder distention, wall thickening, pericholecystic fat stranding, and the presence of gallstones within the gallbladder were observed (Figure 1A).

Figure 1 Simultaneous pancreatic cancer, obstructive jaundice, and acute cholecystitis. A: CT image of pancreatic head mass and acute calculous cholecystitis; B: Endoscopic ultrasound-guided biopsy of the pancreatic mass; C: Endoscopic view of tumor infiltration of the second part of the duodenum and the papilla of Vater; D: Endoscopic ultrasound image of acute cholecystitis.

FINAL DIAGNOSIS

Clinical examination and imaging studies revealed obstructive jaundice, a distended and inflamed gallbladder, and a mass in the pancreatic head, raising suspicion for pancreatic cancer and acute cholecystitis.

TREATMENT

A single-session plan was initially made to perform EUS-FNB of the pancreatic mass for diagnostic confirmation along with ERCP for biliary decompression. The EUS-FNB was successfully performed using a Fujifilm EG-740UT curved linear EUS scope via the duodenal bulb without complications (Figure 1B). However, endoscopic visualization revealed tumor infiltration of the second part of the duodenum and the papilla of Vater, rendering ERCP technically unfeasible (Figure 1C). An attempt to perform an EUS-guided choledochoduodenostomy was made using the same linear echoendoscope. Nevertheless, the procedure was significantly complicated by tumor-related distortion of the duodenal bulb that impaired endoscopic orientation and made it extremely difficult to identify a safe and stable window to access the common bile duct.

Given the complexity of the case, including the concomitant acute cholecystitis (Figure 1D), an EUS-guided gallbladder drainage (EUS-GBD) was planned. After confirming the patency of the cystic duct, a free-hand trans bulb EUS-GBD was performed without the use of a guidewire. A 10 mm × 10 mm Hot-Axios^TM (Boston Scientific, United States) lumen-apposing metal stent was successfully placed, achieving effective gallbladder drainage with pus draining into the bulb (Figure 2A-C). The procedure was completed without any complications, and CT confirmed proper placement of the stent (Figure 2D).

Figure 2 Endoscopic ultrasound-guided gallbladder drainage. A: Endoscopic ultrasound view of the lumen-apposing metal stent (LAMS) inside the gallbladder; B: LAMS placed through the duodenal bulb; C: Pus coming from the gallbladder; D: CT image of the LAMS between the gallbladder and bulb. LAMS: Lumen-apposing metal stent.

OUTCOME AND FOLLOW-UP

Both the patient’s symptoms of acute cholecystitis and jaundice soon improved. Histopathological evaluation of tissue samples obtained from the EUS-FNB confirmed the diagnosis of pancreatic adenocarcinoma, and the patient was subsequently referred to oncology for palliative care.

DISCUSSION

This case exemplified the use of EUS-guided interventions to manage simultaneous pancreatic cancer, obstructive jaundice, and acute cholecystitis in a patient who was not a candidate for traditional procedures due to technical limitations. The combination of EUS-FNB and ERCP is well-documented in the literature, and the presence of a highly skilled biliopancreatic endoscopist is crucial for achieving optimal results and reducing management times[8]. Indeed, EUS-GBD is an established procedure when ERCP fails as seen in this case. EUS-GBD is gaining recognition as a viable alternative to more established techniques, such as EUS-guided choledochoduodenostomy and EUS-guided hepaticogastrostomy, for biliary decompression[9,10]. However, when EUS-GBD is used to relieve jaundice, confirming cystic duct patency is essential to avoid suboptimal drainage. In this case cystic duct patency was successfully confirmed via EUS, providing the dual benefit of resolving calculous acute cholecystitis and alleviating jaundice.

CONCLUSION

This case demonstrated the successful use of a single-session EUS-FNB and EUS-GBD for the management of an elderly patient with simultaneous pancreatic cancer invading the duodenal wall, obstructive jaundice, and acute cholecystitis. This combined endoscopic approach not only provided an effective means of relieving symptoms but also facilitated a rapid diagnosis of pancreatic adenocarcinoma.