A 79-year-old
woman presented with obstructive jaundice was admitted to the hospital. The patient's
workup revealed chronic liver disease, contracted gall bladder over stones,
dilated CBD with moderate intrahepatic biliary radicles dilatation, and pancreatic
head lesion. Bilirubin was 13.5 and direct was 11.22mg/dl. Alkaline phosphatase
was 675 (normal up to 104). There was moderate normocytic normochromic anemia (HB
level 9.5 gm/dl). Serum albumin was 2.9. ALT was 66.4 and AST was 80.1.
The patient
underwent an ERCP endoscopy. The scope revealed a large duodenal mass at the
site of the papilla with overlying bleeding. An attempt for cannulation was
failed. Antegrade cholangiogram was done by an interventional radiologist and
revealed hugely dilated CBD and moderate dilated intrahepatic biliary radicles
with distal CBD stricture (duodenal side). A guidewire was inserted through the
antegrade approach and a partially covered metallic stent was deployed through
the anterograde approach(video). The insertion of the stent was visualized with
the assistance of the endoscopist (this time we use the duodenoscope, not the ERCP
scope) (video). Multiple biopsies were taken from the mass by the upper
digestive endoscopy and we are waiting for the histopathological results.
QUESTIONS:
Did the
upper digestive endoscopy add value when used instead of the ERCP scope?
Do you
agree to use upper digestive endoscopy before the ERCP scope in cases of
malignant obstructive jaundice?
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