G-Tube Guided Endoscopic Retrograde Cholangiopancreatography; A Lifesaving Procedure

Introduction: Acute cholangitis is a consequence of obstruction and infection of the biliary tract. Endoscopic retrograde cholangiopancreatography (ERCP) is key in the management of choice as acute cholangitis as stone extraction and/or stent insertion establishes biliary drainage and relief of infection. Anatomical variation following Roux-en-Y gastric bypass surgery or patients with esophageal obstructions like in our case are prone to make the early intervention by ERCP a challenge . We describe a case report of septic cholangitis in a patient whom gastrostomy tube (G-tube) access allowed the performance of successful ERCP which was otherwise impossible. Case report: 75-year-old male with multiple comorbidities and esophageal cancer status post G-tube placement for malnutrition who presented with cholangitis. On admission, the patient had fever, nausea and decrease in level of activity. His initial evaluation showed that the patient had a sepsis with a fever of 99.6, leukopenia with WBC of 2.0, elevation in the liver enzymes with alkaline phosphatase of 238, alanine aminotransferase of 48, total bilirubin 1.2 and lactic acid of 3.2. His infectious workup included blood cultures that grew Enterobacter cloacae. His CT scan showed stone in the common bile duct. MRCP demonstrated a 1.3 cm obstructive distal common bile duct stone with extrahepatic and intrahepatic biliary dilatation. ERCP was unsuccessful due to a partially obstructing esophageal mass. After changing to a small pediatric endoscope, the scope was able to be passing the mass and a showed a good visualization of the ampulla but therapeutic intervention was not successful. Patient was brought back for a second attempt using his G-tube. A wire was passed under fluoroscopy adjacent to the G-tube then the G-tube was removed. Then a stent anchoring system was used with 3 anchors being placed. Subsequently, an axios stent (lumen-apposing self-expandable metallic stent) was placed under combined direct vision and fluoro. The stent was then sutured down in order to prevent migration. Following placemen of the stent balloon dilatation was performed inside the stent up to 15 mm in size. Following dilatation over a jag wire the ERCP scope was passed through the stent and used to cannulate the ampulla. A sphincterotomy was performed and the stone was removed with a balloon catheter. Following completion of the stone removal the Axios stent was then removed and a G-tube was replaced and confirmed with contrast for position. The patient tolerated the procedure without any complication, his bilirubin normalized and the patient discharged in stable condition the next day on a total course of 14 days of antibiotics. Conclusion: In cholangitis patient with limited access, G-tube sites provide a useful access value to examine the gastrointestinal track for therapeutic intervention.