NAVIGATING HEPATOLITHIASIS: A CASE REPORT OF ENDOSCOPIC MANAGEMENT OF HEPATOLITHIASIS IN A TERTIARY CARE SETTING

Document Type

Conference Proceeding

Publication Date

6-1-2024

Publication Title

Gastrointest Endosc

Abstract

Introduction: Hepatolithiasis is a disease endemic to East Asia characterized by the formation of intrahepatic ductal stones, typically proximal to the confluence of the right and left hepatic ducts. It can be complicated by repeated cholangitis, biliary strictures, liver abscesses, cirrhosis, or cholangiocarcinoma. The gold standard for treatment is surgical hepatectomy, however as treatment approaches have evolved, there are now safe and effective endoscopic alternatives. We present a rare case of hepatolithiasis within the United States managed with cholangioscopic interventions. Case Description: A 58 year old Caucasian female in the Northern United States had presented with acute onset abdominal pain, jaundice, and elevated liver enzymes (ALT (858 IU/L), AST (668 IU/L), T.bili (5.2 mg/dl), D.bili (3.3 mg/dl), ALP (IU/L)). Cross-sectional imaging revealed areas of substantial intrahepatic ductal dilation in the right and left lobe of the liver (Figure 1). Subsequently, she underwent an endoscopic retrograde cholangiopancreatography (ERCP) with findings of a single 18 mm saccular/cystic dilation in a secondary left intrahepatic branch. A biliary sphincterotomy was performed and a filling defect was found within the dilated segment on an occlusion cholangiogram (Figure 2A). Single operator cholangioscopy was then performed and no mass, lesion or stricture was found in the extrahepatic bile duct, bifurcation or left and right main hepatic ducts. Two large stones were found in the dilated left segment and were removed via cholangioscopy-assisted electrohydraulic lithotripsy (EHL) and balloon extraction (Figure 2B). Brushings and biopsies were obtained from the dilated segment (which did not reveal any malignancy or dysplasia) and a transpapillary double pigtail plastic stent was placed to ensure optimal biliary drainage. The patient’s symptoms and liver enzymes improved. She subsequently had an interval follow up ERCP with repeat cholangioscopy which confirmed clearance of hepatolithiasis. The biliary stents were therefore not replaced. The patient is currently following with the Hepatobiliary Surgery service for imaging surveillance. She is being treated empirically with ursodiol and is currently doing well. Discussion: We present a patient with symptomatic hepatolithiasis that was successfully treated using an endoscopic approach. Several prior retrospective studies and reviews have described surgical resection as the definitive mainstay of treatment for hepatolithiasis and the majority of cases were in patients of East Asian descent. More recently, endoscopic intervention has been shown to be effective as well. This case provides supportive evidence for the utility of surgery-sparing cholangioscopy-assisted EHL as a safe and effective part of multidisciplinary management of hepatolithiasis.

Volume

99

Issue

6

First Page

AB117

Last Page

AB118

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