EUS Directed Trans-Gastric ERCP (EDGE) Procedure in a Patient with Cholangitis and a Large Marginal Ulcer

Manjakkollai P. Veerabagu, MD *¹, Travis R. Smith ²

1. AnMed Health Gastroenterology, Affiliate Associate Professor Medical University of South Carolina, Charleston, SC
2. DO, PGY-2 AnMed Health Family Medicine Residency.

*Correspondence to: Manjakkollai P. Veerabagu, AnMed Health Gastroenterology, Affiliate Associate Professor Medical University of South Carolina, Charleston, SC.

Copyright

© 2024 Manjakkollai P. Veerabagu. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 17 January 2024

Published: 27 January 2024

75-year-old man with chronic kidney disease on hemodialysis, atrial fibrillation and history of Roux en-Y gastric bypass was admitted with cholangitis from bile duct stones. His blood culture grew Escherichia coli, klebsiella pneumoniae and Enterococcus faecium. EUS directed trans-gastric ERCP (EDGE) was planned. EGD showed severely inflamed gastric pouch with a large marginal ulcer (Fig A). The patient was too unstable for Lap assisted ERCP. The patient underwent successful single session EDGE with placement of a 20 mm x 10 mm Axios stent (Boston Scientific Corp, Marlborough, Mass, USA) through an area that did not involve the large ulcer (Fig B). Plastic stent was placed initially and two weeks later, the stones were successfully removed using cholangioscope and EHL. Four weeks later EGD showed gastro gastric fistula (Fig C) and LAMS has been spontaneously expelled. The ulcer has completely healed. The fistula was closed after APC ablation by endoscopic suturing (using Apollo Endo stitch) (Fig D). Patient was discharged in stable condition and follow up one month later the patient was doing well.

Figure A, B, C, D