Treatment of Ischemic Intrahepatic Biloma with EUS-Guided Hepaticogastrostomy With Placement of a Fully Covered Self-Expanding Metal Stent (FCSEMS) in a Liver Transplant Recipient

Introduction: Biloma results from full thickness necrosis of the bile duct wall with extravasation of bile into the liver parenchyma or abdominal cavity and are associated with higher rates of infection, graft loss and mortality. In non-surgical candidates, endoscopic ultrasound (EUS) guided drainage of a biloma may be a safe and viable treatment option for those who fail conventional therapies. Case Description/Methods: We describe the case of a 64-year-old woman with a history of autoimmune-related cirrhosis who had an orthotopic liver transplant (OLT) in 1995 and a second OLT in 2011 due to graft failure due to recurrent autoimmune hepatitis which was complicated by hepatic artery thrombosis leading to ischemic cholangiopathy resulting in biliary strictures requiring multiple endoscopic retrograde cholangiopancreatography (ERCP) procedures with biliary stent placements. She has a history of multiple admissions for recurrent cholangitis and presented to clinic with complaints of abdominal pain and intractable pruritus. She had a magnetic resonance cholangiopancreatography (MRCP) that showed bilomas with intrahepatic biliary ductal dilation with periductal enhancement in the left greater than right lobe but no fluid collection to suggest abscess (image A). She was deemed a poor surgical candidate and referred for endoscopic transluminal drainage as she had failed conventional ERCP. Patient was noted to have an abnormal left hepatic lobe with noted amorphous lesion that appeared to be a dilated left intrahepatic bile duct on EUS (image B). A 19-gauge FNA needle was used to puncture the left hepatic duct (LHD)(image C) and contrast was injected to confirm the location. A cholangiogram demonstrated diffusely dilated LHDs. A needle-knife catheter was advanced to the stomach wall over a wire and electrocautery was used to create a fistulous tract from the stomach into the left intrahepatic duct. Subsequently, a 10 mm x 10 cm fully covered self-expanding metal stent (FCSEMS) was deployed with the distal end in the biloma of the LHD and the proximal end in the body of the stomach. Finally, a 7 French 20 cm double pigtail plastic stent was deployed across the FCSEMS for anchoring (image D). Subsequently after the procedure, patient had improvement of the abdominal pain, pruritus, and laboratory findings. Discussion: Our case demonstrated that EUS-guided hepaticogastrostomy stent placement, in a post-OLT patient who is a poor surgical candidate, is an effective and safe alternative when conventional ERCP has failed.Figure 1.: Image A: MRCP showing bilomas left greater than right liver lobe with intrahepatic biliary ductal dilation with periductal enhancement Image B: EUS demonstrating dilated left biliary duct Image C: EUS demonstrating 19 gauge FNA needle used to puncture the left hepatic duct (LHD) Image D: 10 mm x 10 mm fully covered self-expanding metal stent (FCSEMS) was deployed with the proximal end in the body of the stomach with an anchoring pigtail catheter