S5269 A Novel Use of Digital-Assisted Cholangioscopy to Bypass Pyloric Stenosis and Visualize the Distal Duodenum Through the Excluded Stomach for Evaluation of Imaging Findings Concerning for an Ampullary Mass

Introduction: This case highlights the use of digital-assisted cholangioscopy in a novel way that allowed for a means of diagnosis that did not delay patient care. It highlights the use of specialized endoscopic tools in innovative ways to provide patient care. Case Description: A 67-year-old woman with history of vascular dementia and prior Roux-en-Y gastric bypass presented to the emergency department from a long-term care facility with generalized weakness and weight loss. She underwent computed tomography imaging of the chest, abdomen and pelvis. Imaging revealed findings concerning for double duct sign as well as wall thickening of the gastric antrum. Further imaging with magnetic resonance cholangiopancreatography redemonstrated common bile duct dilation and concern for an ampullary mass. GI was subsequently consulted and esophagogastroduodenoscopy was performed. Esophagogastroduodenoscopy revealed anatomy compatible with prior gastric bypass and erosion/ulceration at the gastrojejunal anastomosis. The decision was made to perform an endoscopic ultrasound-directed endoscopic retrograde cholangiopancreatography for further evaluation. The gastrogastrostomy was created with endosonographic guidance using a 19 gauge needle; subsequently a 20 × 10 mm lumen-apposing metal stent was deployed and anchored via endoscopic suturing. Through this gastrogastrostomy, the excluded stomach was examined with a gastroscope, although there was an area of stenosis at the pylorus that could not be traversed. The decision was made to switch to a side-viewing duodenoscope. The duodenoscope was advanced to the pylorus. Using a guidewire, the area of stenosis was able to be traversed and the distal duodenum was visualized via digital-assisted cholangioscopy. A circumferential, ulcerated and erythematous mass-like area was noted in the distal duodenum and biopsies were obtained via the cholangioscope. The duodenal mass biopsies showed poorly differentiated invasive carcinoma. Following consultation with oncology and surgical services, the patient opted to pursue hospice care as they were deemed not a candidate for systemic chemotherapy or surgical intervention. Discussion: The decision to use digital-assisted cholangioscopy in a novel way allowed the patient to received a timely diagnosis. Although the patient ultimately pursued hospice care, this case highlights the unconventional use of endoscopic tools to obtain diagnostic information in a timely manner.