Successful biliary drainage with peroral direct cholangioscopy in a patient with Roux-en-Y hepaticojejunostomy for congenital biliary dilatation.

The diagnostic and therapeutic effectiveness of combined double-balloon endoscopy with a short endoscope and peroral direct cholangioscopy with an ultraslim endoscope in patients who have altered gastrointestinal anatomy has been demonstrated [1–5]. We describe successful biliary drainage with a short double-balloon endoscope and peroral direct cholangioscopy in a patient who had cholangitis after surgery for congenital biliary dilatation. A 61-year-old woman with a surgical history of hepaticojejunostomy and Rouxen-Y reconstruction for congenital biliary dilatation (Todani type IV-A) was admitted because of high fever associated with leukocytosis (white cell count 14100/μL [normal 3500–8500]) and elevated C-reactive protein (21.1mg/dL [normal 0.0–0.3]). Contrast-enhanced computed tomography showed a limited cystic dilatation of the posterior bile duct with multiple stones and peripheral enhancement of the cystic dilatation (●" Fig.1). Magnetic resonance cholangiopancreatography (MRCP) showed dilatation of both intrahepatic bile ducts that was congenital biliary dilatation (●" Fig.2). Because cholangitis of the posterior bile duct was suspected, the patient underwent double-balloon endoscopy for endoscopic retrograde cholangiography with a short enteroscope (EI-530B; Fujifilm, Tokyo, Japan). The hepaticojejunostomy anastomosis was widely patent (●" Fig.3). We sought the posterior branch with the guidewire but were unsuccessful because the intrahepatic bile ducts were widely dilated. Therefore, we exchanged the double-balloon endoscope for an ultraslim endoscope (EG-L580NW, outer diameter 5.8mm, working channel 2.4mm; Fujifilm), leaving the overtube in place with balloon inflation. The ultraslim endoscope was advanced to the hepaticojejunostomy anastomosis and directly inserted into the intrahepatic bile ducts. We identified a membranous stricture of the posterior branch (●" Fig.4) and cannulated it successfully. Cholangiography revealed multiple stones in the dilated posterior bile duct (●" Fig.5). We performed biliary drainage with a 6-Fr double-pigtail plastic stent (●" Fig.6). Bacterial culture of the bile juice revealed Escherichia coli overgrowth, and cytologic analysis showed no malignancy. A definitive diagnosis of cholangitis was obtained. Thereafter, the patient’s general condition and the results of clinical analyses rapidly improved.