P4523 - Successful Removal of a Giant Intractable Common Bile Duct Stone (4 cm) Using Electrohydraulic Lithotripsy and Cholangioscopy During a Single ERCP Session in a 92-Year-Old Patient

Akshay Sharma, MBBS¹, Nirav Agrawal, MD, MPH², Muhammad Kazi, MD¹, Rahul Kumar, MD³, Sanmeet Singh, MD¹
1Luminis Health Anne Arundel Medical Center, Annapolis, MD; 2Anne Arundel Medical Center, Luminus Health, Annapolis, MD; 3North Central Bronx Hospital, Bronx, NY

Introduction: Common bile duct (CBD) stones can lead to complications, including cholangitis, pancreatitis, and sepsis. Endoscopic retrograde cholangiopancreatography (ERCP) is the preferred method for CBD stone removal. The extraction technique is chosen on the stone size: balloon/basket extraction for stones ≤1 cm, and cholangioscopy-assisted lithotripsy for stones >1 cm. We present a case of a 92-year-old woman with a giant intractable CBD stone (4 cm in diameter) successfully removed by Electrohydraulic Lithotripsy (EHL) assisted by cholangioscopy in a single session of ERCP.

Case Description/

Methods: A 92-year-old female with a history of cholecystectomy presented with worsening right upper quadrant abdominal pain, fever, and elevated liver enzymes. MRCP revealed a 4 cm stone in the CBD. During ERCP, a cholangiogram confirmed the presence of a 4 cm filling defect in the mid-common bile duct with upstream biliary ductal dilation. Cholangioscopy was performed for direct visualization of the stone. Two EHL probes were used to fragment the stone, fragments removed successfully via balloon extraction, and a normal occlusion cholangiogram was obtained.

Discussion: Studies show that elderly patients (≥80 years old) often require an average of 2.9 procedures to clear the bile duct, with a mean stone size of 1.6 cm. A search of >500 PubMed articles yielded no reports of similar intractable CBD stones (≥4 cm) in post-cholecystectomy patients removed in a single ERCP session without complications (image 1). Typically, stones of this size require Percutaneous Transcholecystic Cholangioscopy, laparoscopic, or open surgical intervention for removal. In this case, EHL was effectively used for the removal of the giant stone. EHL can be an ideal method for giant stone removal in elderly patients with multiple comorbidities who may not be suitable candidates for surgery. Performing a single-session ERCP is beneficial as it minimizes the number of procedures required, reducing both the anesthesia burden and procedural risks. This is particularly important in elderly where quality of life and the risk of complications associated with repeated procedures are significant considerations. When evaluating the risks and benefits of ERCP in elderly patients, factors such as frailty, comorbidities, and polypharmacy should be prioritized over age alone. This approach can improve patient outcomes by reducing unnecessary procedures and complications, ensuring that elderly patients receive effective, less invasive care when possible.


Figure: Image 1 description: A, B shows fluoroscopic defect before and after EHL during ERCP.


Figure: Image 2 description shows CBD stone fragments being cleared out.

Disclosures:
Akshay Sharma indicated no relevant financial relationships.
Nirav Agrawal indicated no relevant financial relationships.
Muhammad Kazi indicated no relevant financial relationships.
Rahul Kumar indicated no relevant financial relationships.
Sanmeet Singh indicated no relevant financial relationships.

Akshay Sharma, MBBS¹, Nirav Agrawal, MD, MPH², Muhammad Kazi, MD¹, Rahul Kumar, MD³, Sanmeet Singh, MD¹. P4523 - Successful Removal of a Giant Intractable Common Bile Duct Stone (4 cm) Using Electrohydraulic Lithotripsy and Cholangioscopy During a Single ERCP Session in a 92-Year-Old Patient, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.