Background

Multimodal Therapy for Biliary Tract Disease in a Bypass Patient Background:The patient is a 70 year-old who underwent gastric bypass elsewhere in 2010. She came to our ED after a coughing fit that resulted in severe left upper abdominal wall pain. A CT scan showed a left rectus sheath hematoma. Additionally, she was found to have cholelithiasis and choledocholithiasis. As these were asymptomatic, she was sent home, and an outpatient GI consultation was scheduled. GI Evaluation:GI recognized that the patient had bypass anatomy. They discussed transremnant ERCP, double balloon enteroscopy and ERCP, as well as creation of a gastrogastric fistula with a self-expanding stent, followed by ERCP. As none of these options were considered optimal, she was referred for surgical evaluation. Surgical Evaluation:An outpatient biliary ultrasound and follow-up labs were obtained. The patient had an alkaline phosphatase of 250 but her other lab tests were normal. The ultrasound showed a 7mm common bile duct diameter, with no choledocholithiasis. Based on this, she was scheduled for cholecystectomy and IOC; if no stones were present, we would be done. Small common duct stones would be addressed by on-table transremnant ERCP. Larger stones would be removed via common bile duct exploration. Treatment:The patient underwent cholecystectomy. IOC showed large common duct stones. The four known stones were removed by CBDE, with assistance of flexible choledochoscopy and balloon catheter retrieval. Completion cholangiogram showed an additional stone. This was removed radiologically via PTC. The patient subsequently did well.