S5353 Peroral Cholangioscopy-Directed Electrohydraulic Lithotripsy: An Effective Therapeutic Strategy for Challenging Intrahepatic Stones

Introduction: Peroral cholangioscopy (POC) is a well-established diagnostic modality for intraductal visualization of various biliary diseases, and in combination with electrohydraulic lithotripsy (EHL), represents an efficacious therapeutic strategy for challenging bile duct stones. Alternative treatment approaches include percutaneous transhepatic cholangioscopy, especially in cases of altered surgical anatomy or intrahepatic stones. Here, we present a case of successful intrahepatic stone removal accomplished by POC-directed EHL. Case Description: A 27-year-old woman with a history of intrahepatic cholestasis of pregnancy presented with an 8-day history of epigastric and right upper quadrant abdominal pain. Initial labs were significant for an elevated alkaline phosphatase 434 U/L, ALT 1,014 U/L, AST 829 U/L and total bilirubin 3.0 mg/dL. CT abdomen pelvis with IV contrast was remarkable for gallbladder distension with trace pericholecystic fluid, dilated intrahepatic biliary ducts with right lobe prominence and no common bile duct (CBD) dilation. Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic ultrasound revealed gallstones, main and bilateral hepatic duct dilation, and one CBD stone requiring biliary sphincterotomy, balloon extraction and plastic biliary stent placement. A subsequent ERCP with POC was performed 3 months later. She was found to have persistent dilation of the right intrahepatic duct with multiple stone impactions and a stricture at the site of stone impaction. Stone fragmentation was achieved via POC-directed EHL. The biliary tree was swept with complete stone removal followed by stent placement at the site of the right hepatic duct stricture. Repeat CT scan approximately one month later showed no intrahepatic dilation. She underwent robotic cholecystectomy with an uneventful course and normalization of liver enzymes. Discussion: Intrahepatic biliary duct obstruction presents a diagnostic and therapeutic challenge to endoscopists. This case illustrates the viability of POC-directed EHL as a tool for peripheral bile duct stone localization and removal. Concern for intrahepatic duct involvement on imaging should prompt a multistage treatment approach which includes POC-directed EHL to ensure complete proximal stone clearance prior to surgical planning. Future research should assess the efficacy of POC-directed EHL as part of a standardized approach in the management of intrahepatic stone impaction.