Endoscopic ultrasound-guided choledochoduodenostomy with novel use of contrast- enhanced harmonic imaging

Since it was first described in 2001 [1], endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) has been increasingly used as an alternative for biliary decompression after failed endoscopic retrograde cholangiopancreatography (ERCP). EUS-CDS has an overall technical success rate of more than 90% [2, 3], but puncturing the common bile duct (CBD) can be challenging in patients with hemobilia because it presents as a heterogeneous echogenicity. Here, we present a patient for whom EUS-CDS was successfully performed under contrastenhanced harmonic EUS (CH-EUS) guidance. A female patient in her eighties with advanced duodenal cancer was referred to our hospital for treatment of recurrent obstructive jaundice. She had previously undergone duodenal metal stent placement and an external gallbladder drainage catheter had been placed for biliary obstruction due to direct cancer invasion of the ampulla. An abdominal computed tomography (CT) scan revealed bile duct dilatation and high-density components in the CBD, suggesting hemobilia (▶Fig. 1). As her CT scan showed a dilat-ed CBD, we elected to perform EUS-CDS. B-mode EUS revealed heterogeneous echogenicity in the CBD, but the visualization was poor. To determine whether there was active bleeding and to delineate the CBD from the surrounding tissues, we performed CH-EUS. Immediately after intravenous infusion of 0.015mL/kg of a sonographic contrast agent (Sonazoid; E-Videos