Korean J Gastroenterol.  2020 Oct;76(4):215-219. 10.4166/kjg.2020.76.4.215.

Removal of a Large, Intractable Common Bile Duct Stone by Direct Peroral Cholangioscopy Using Upper Gastrointestinal Endoscopy and Polypectomy Snare

• Heo J
• Jung MK

• KMID: 2507770
• DOI: http://doi.org/10.4166/kjg.2020.76.4.215

Abstract

ERCP is the standard treatment for common bile duct stones. On the other hand, 10-15% of cases involve intractable common bile duct stones, which cannot be treated by conventional biliary sphincterotomy with a stone retrieval method. Large bile duct stones are typically managed by mechanical lithotripsy and endoscopic papillary large balloon dilatation. Peroral cholangioscopy techniques can be applied if this technique fails. In the present case, a 67-year-old woman had a large common bile duct stone that could not be retracted using the conventional ERCP stone extraction method. The common bile duct stone was eventually removed by direct peroral upper gastrointestinal endoscopy and a polypectomy snare.

Keyword

Choledocholithiasis; Cholangiopancreatography; endoscopic retrograde; Endoscopy; gastrointestinal; therapeutic use; Lithotripsy

Figure

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  Fig. 1 Abdominal computed tomography on the admission day. The intrahepatic duct, common hepatic duct, and common bile duct (CBD) were dilated. The large CBD stone, size 54×32 mm, was observed in the CBD (arrow). A cystic lesion with peripheral rim enhancement, 50 mm in size, was observed in liver segment 3 (arrowhead). The gallbladder (asterisk) was dilated.

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  Fig. 2 Removal of common bile duct (CBD) stone by direct peroral cholangioscopy using upper gastrointestinal endoscopy and polypectomy snare. (A) A huge CBD stone showed brown pigment characteristics. The CBD was dilated significantly by the stone. (B) The CBD stone had been cracked into two pieces by grasp with snare polypectomy at the midline of the stone (arrow). (C) During cracking the stone by polypectomy snare, some fragmentations were extracted by the snare. (D) The upper gastrointestinal endoscope with snare was inserted inside the CBD.(E) After several attempts of the polypectomy snare technique, the stone was fragmented into several small pieces, which were extracted by basket and retrieval balloon.

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  Fig. 3 Follow-up cholangiogram by percutaneous transhepatic cholangioscopy before removal showed no remnant common bile duct stone.

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