Endoscopic ultrasound for cholangiocarcinoma re-evaluation after Wallstent placement.

(MRI) cholangiography and endoscopic retrograde cholangiography (ERC), endoscopic ultrasound (EUS) readily visualizes common bile duct (CBD) and allows the diagnosis of bile duct masses or strictures (1). Once a Wallstent® has been placed, re-evaluation of the bile duct and stent patency may be difficult. We present the case of a patient with a Klastkin tumor to show the utility of EUS in this setting. A 55 year old male, smoker, with medical history of ischemic heart disease and atrial fibrillation, was first admitted to our hospital because of jaundice. The diagnosis of Klastkin tumor IIIA-IV was established based on contrast-enhanced computed tomography (CECT) and ERC. The tumor was considered to be not resectable due to relevant portal infiltration. An uncovered biliary Wallstent® was placed endoscopically for palliation of jaundice and a palliative chemotherapy with oxaliplatin and gemcitabine was administered. Eighteen months later the patient was admitted again because of jaundice relapse and the suspicion of biliary Wallstent® obstruction due to tumor growth. The exact cause of jaundice could not be demonstrated by CECT, and the obstruction of the Wallstent® could only be suspected. MRI cholangiography provided no further information because of stent-related artifacts, whereas ERC was only able to show complete stop at the very distal portion of the stent. On the contrary, lineal EUS (PENTAX FG-3830UT) precisely revealed the growth of the tumor inside the Wallstent® lumen as the cause of biliary obstruction (Fig. 1). The infiltration of the portal vein could also be confirmed during the procedure (Fig. 2). Finally, a palliative EUS-guided transgastric biliary drainage was placed during the same procedure. Several imaging techniques are used in clinical practice for bile duct evaluation, among them MRI cholangiography, CT scan, ERC and EUS (2). In this context, EUS has proved to be a useful diagnostic tool in patients with obstructive jaundice, as it does not only allow a clear visualization of the neoplasia, but also an accurate local tumor staging (3-5). In a recent study comparing ERC, MRI cholangiography, CT and EUS for evaluation of biliary strictures, Rosch et al. (6) demonstrated the highest diagnostic accuracy for MRI associated with EUS. This supports the previous statement of an international panel of experts regarding the major role of EUS for the diagnosis and staging of biliary tumors in clinical practice (7). Endoscopic ultrasound for cholangiocarcinoma re-evaluation after Wallstent® placement