S5301 Cholangioscopy-Assisted Identification of an Impacted Stone Within a Biliary Anastomotic Stricture

Introduction: Biliary anastomotic strictures are a well-known complication following liver transplantation. We present a unique case of a post-liver transplant anastomotic stricture that was initially not traversable during ERCP, due to a nearly obstructing stone which was only identified on cholangioscopy. Case Description: A 29-year-old man with alcohol-associated cirrhosis who underwent orthotopic liver transplant 9 months earlier presented with elevated liver enzymes, with alkaline phosphatase (ALP) of 227 U/L (30-120 U/L), aspartate aminotransferase (AST) of 75 U/L (8-37 U/L), alanine transaminase (ALT) of 193 U/L (0-50 U/L), and total bilirubin of 0.2 mg/dL (0.1-1.0 mg/dL). MRCP revealed a stricture at the level of anastomosis with upstream biliary dilation to 7 mm. ERCP was performed with a severe stricture identified on cholangiogram. Attempts to traverse the stricture with multiple devices were initially unsuccessful. Cholangioscopy was performed for direct visualization. This revealed an impacted stone at the anastomotic stricture, nearly completely obstructing the biliary lumen. A guidewire was advanced through the cholangioscope past the stone under direct visualization into the donor biliary ducts. This allowed for stone extraction via balloon sweeps. The final cholangiogram showed a severe anastomotic stricture with dilated upstream ducts. The stricture was treated with balloon dilation to 4 mm and placement of a 10 mm × 8 cm fully covered metal biliary stent. The patient’s liver enzymes normalized within 1 week of the procedure. Discussion: Biliary anastomotic strictures are effectively managed with ERCP. In this case, standard techniques could not traverse an apparent severe stricture. Adjunctive cholangioscopy revealed a near-complete obstructing stone impacted at the anastomotic stricture, which had not previously been identified on imaging or cholangiogram. Cholangioscopy enabled successful wire passage into the donor bile ducts and subsequent stone extraction and stricture management. This case highlights the value of cholangioscopy in technically challenging strictures. When conventional ERCP fails, cholangioscopy is a valuable tool for diagnosis and management.