Bile duct adenoma causing recurrent cholangitis: diagnosis and management with targeted Spyglass access and radiofrequency ablation

A 77-year-old man was admitted for evaluation of recurrent episodes of cholangitis. He had undergone endoscopic retrograde cholangiography (ERC) several times for biliary stone disease and for cholecystectomy, and suffered from advanced Alzheimer disease. Abdominal magnetic resonance imaging (MRI) revealed dilatation of the right posterior intrahepatic duct, with aberrant drainage directly into the common hepatic duct. However, multiple attempts to reach this segment by ERC were unsuccessful. The Spyglass system was then used for selective opacification and optical viewing of the aberrant bile duct (Boston Scientific, Natick, Massachusetts, USA).A reddish nodular lesion was seen obstructing the lumen, and targeted biopsies with a 3-Fr Spybite mini-forceps (Boston Scientific) confirmed the presence of an adenoma. The stricture was dilated with a Hurricane 8-mm, 4-cm balloon (Boston Scientific) and the stones were extracted. The Spyscope was removed and two 7-Fr plastic stents placed. Given the patient’s poor mental and general status, we proposed carrying out endobiliary radiofrequency ablation of the stricture. This was done 4 weeks later with a wire-guided Habib EndoHPB (Emcision, London, UK). This case illustrates the potential impact of selective cholangioscopy with the Spyglass system on diagnosis and management of indeterminate biliary strictures.