Case report: Biliary lithotripsy for hepatolithiasis in a patient with hepato-jejunal anastomosis

Author(s): Mohamed Awali*, Maya Mahmoud, Iyad Mallak & Sami Slaba

A 58-year-old patient presented worsening right upper quadrant pain and fever with elevated serum hepatic enzymes. His surgical history was significant for a cholecystectomy and subsequent hepato-jejunostomy. MRI and cholangiography showed diffuse dilatation of intra and extra hepatic bile ducts with multiples intraductal biliary stones especially in the left liver. Endoscopic Retrograde CholangioPancreatography (ERCP) was unsuccessful due to extensive operative history and surgical intervention carried a high mortality risk. Percutaneous biliary drainage was performed which helped resolve the patient’s symptoms, but definite treatment was still required, especially that overpassing a stone on the right side was not possible after many attempts. Percutaneous endoscopic Holmium laser lithotripsy was performed with successful fragmentation of the stone and clearance of the obstruction, without complication. The endoscope was used to help visualize the narrowed anastomosis and to advance a guide wire into the jejunal lumen, allowing internal-external tube placement on the right side. This case is relevant to the growing literature on the management of refractory biliary stones using laser lithotripsy after failed ERCP.