S5206 A Rare Case of Choledocholithiasis Following Endoscopic Ultrasound-Guided Gallbladder Drainage for Acute Cholecystitis

Introduction: Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) with a lumen-apposing metal stent (LAMS) has been increasingly utilized for gallbladder drainage in high-risk surgical candidates with acute cholecystitis. Well-documented complications include stent migration, bile stasis, and bleeding, but biliary obstruction has rarely been reported. Here, we present a case of acute calculous cholecystitis in a non-surgical candidate who underwent EUS-GBD with LAMS and developed biliary obstruction from choledocholithiasis on post-procedure day 1. Case Description: An 86-year-old man with dementia, heart failure, chronic kidney disease, post-ablation atrial fibrillation, and sick sinus syndrome with pacemaker presented for 1 day of right-sided abdominal pain, nausea, and non-bilious emesis. His vitals were stable, and he had mild right upper quadrant tenderness. Labs revealed WBC 10.4K, AST 46 U/L, ALT 26 U/L, alkaline phosphatase (AP) 87 U/L, total bilirubin 1.0 mg/dL, and lipase 113 U/L. Computed tomography abdomen identified a distended gallbladder, peri-cholecystic fluid, and layering sludge suggestive of acute cholecystitis. General surgery evaluated the patient, but he was deemed a poor surgical candidate, therefore gastroenterology was consulted for endoscopic intervention. He underwent EUS-GBD, creating a cholecystoduodenostomy in the second part of the duodenum, via deployment of a 10 mm × 10 mm LAMS and coaxially placed a 7 French plastic double-pigtail stent. On post-procedure day 1, he had an elevated AST 781 U/L, ALT 573 U/L, AP 173 U/L, and total bilirubin 5.8 mg/dL. Magnetic resonance cholangiopancreatography (MRCP) was limited by post-procedural pneumobilia and EUS confirmed choledocholithiasis. On endoscopy, the LAMS was widely patent. Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy successfully removed 2 gallstones. He was discharged in stable condition after labs normalized. Discussion: EUS-GBD with LAMS allows for effective gallbladder drainage and is well tolerated. While malignancy-related biliary obstruction has been reported following EUS-GBD, only 1 study has reported choledocholithiasis after EUS-GBD with LAMS. This is the first report of choledocholithiasis after EUS-GBD with both LAMS and a pigtail stent. Choledocholithiasis in this setting may result from dislodgement of a retained gallstone during stent placement, wire coiling in the gallbladder or saline flush into the cystic duct. Therefore, clinicians should consider post–EUS-GBD choledocholithiasis in calculous cholecystitis patients who develop post-procedural jaundice or transaminitis.