| Caso do mês - janeiro 2024 | Case of the month - january 2024

Everything, everywhere, all at once!

Joana Revés1, Bárbara Morão1, Catarina Fidalgo1, Luísa Glória1, Rui Loureiro1
1 Serviço de Gastrenterologia, Hospital Beatriz Ângelo, Loures, Portugal


A 69-year-old previously healthy woman presented to the emergency department with a one-week history of dark urine, nausea, pale stools, back pain, and early satiety with bloating and vomiting. Physical examination revealed jaundice without abdominal pain. Blood tests demonstrated significantly elevated bilirubin levels (total 7.6mg/dL, conjugated 5.8mg/dL) and abnormal liver enzymes. Imaging revealed a pancreatic head neoplasm, with duodenum invasion and involvement of the gastro-duodenal artery, with multiple liver metastases, staged as a cT2N1M1 (Figure 1). After multidisciplinary discussion, palliative chemotherapy was recommended due to the irresectable nature of the lesion preceded by biliary drainage.

                                                                                         Figure 1. Common bile duct dilation upstream to the pancreatic head neoplasia

An initial attempt of an ERCP was hindered by a duodenal stricture due to neoplastic infiltration that limited the access to the papilla. A subsequent evaluation was proposed using endoscopic ultrasound (EUS)-guided biliary drainage (EUS-BD) and due to the worsening of the gastric outlet obstructive symptoms, a combined EUS-guided digestive palliation was proposed. A linear echoendoscope was used, with identification of the common bile duct (CBD) with significant dilation (15mm) where an EUS-choledocoduodenostomy (EUS-CD) was performed using a lumen-apposing metal stent (LAMS) of 6x8mm with an electrocautery delivery system (Figure 2).