An Atypical Case of Metastatic Esophageal Adenocarcinoma Causing Biliary Obstruction and Duodenal Infiltration Requiring EUS-Guided Choledochoduodenostomy

Esophageal adenocarcinoma (EAC) is an aggressive malignancy with a poor prognosis, especially in advanced stages. Common metastatic sites include the liver, lungs, adrenal glands, lymph nodes, and bones; however, metastasis to the biliary tree is exceedingly rare. We report the case of a 50-year-old male with a history of testicular cancer in remission and metastatic EAC involving the liver, lungs, adrenal glands, peritoneum, bones, and lymph nodes. The patient presented with acute onset jaundice but no abdominal pain, fever, or gastrointestinal symptoms. Laboratory findings revealed significant cholestasis, and imaging demonstrated biliary tree dilation with obstruction at the distal common bile duct. ERCP was unsuccessful due to duodenal invasion by the tumor, which precluded access to the biliary system. Endoscopic ultrasound-guided biliary drainage was performed, and a stent was successfully placed. The patient subsequently developed post-ERCP pancreatitis, which was managed conservatively with intravenous fluids. This case illustrates a highly uncommon metastatic pattern of EAC, with involvement of both the biliary tree and the duodenum, leading to obstructive jaundice and necessitating advanced endoscopic intervention. The combination of widespread metastasis, duodenal obstruction, and biliary involvement makes this presentation exceptionally rare. It also underscores the importance of recognizing atypical manifestations of metastatic EAC and highlights the critical role of endoscopic ultrasound in managing complex biliary obstructions when standard approaches fail. To our knowledge, very few cases of EAC metastasizing to the biliary tree have been reported, making this case a valuable addition to the medical literature and clinical understanding of EAC.