Dr. James Tabibian, Director of the Advanced Gastroenterology Center at Adventist Health Glendale, discusses an unusual case of choledocholithiasis in a patient who had recently given birth. The patient presented with abdominal pain, vomiting, and jaundice. She was referred to Dr. Tabibian for further evaluation and management following a failed Endoscopic Retrograde Cholangiopancreatography (ERCP) at a nearby institution. After a comprehensive review of imaging studies and other clinical elements, Dr. Tabibian and his team performed an EUS-directed ERCP, identifying a large stone in the bile duct that was causing a high-grade obstruction. Listen to learn about the cholangioscopic tools and techniques Dr. Tabibian used to manage this complex case.
Hi, I'm Doctor James Tobibian, a gastroenterologist and interventional endoscopist and also the medical director of the Advanced GI Center at Adventist Health Glendale. I've been the director here for approximately 6 months, and during that period of time I'm very pleased to say that we have expanded our procedural capabilities, our procedure volume, as well as the, the breadth and depth of. Cases that we're able to take on and help treat when many people think of a community hospital, they don't think of a high level of capability or a high level of expertise, but this isn't an ordinary community hospital we're essentially a tertiary referral center with a vast array of subspecialists in gastroenterology, but also in supporting specialties and subspecialties. And as such we're able to offer a very uh diverse array of services for a diverse patient population and a diverse set of uh disorders that we might encounter. Just a few weeks ago we had a patient who was transferred here to Adventist Health Glendale for a. Very challenging and unique scenario. She had just delivered a baby. She was a young lady and uh after doing so she became jaundiced. Her eyes were yellow, her skin was yellow, and all of a sudden after becoming jaundiced, she developed severe abdominal pain, went to the hospital and was found to have not only acute pancreatitis but what seemed to be something blocking her bile duct. She uh was ultimately transferred to us because. The doctors there were afraid to do an ERCP procedure for her uh to to see what's inside the bile duct. She had contraindications to undergoing MRI so that was out so it was felt that she should be transferred to a higher level of care center and that was us, and we were fortunate to to receive her and we reviewed her records and came up with a plan and uh sure enough we did her ERCP procedure. Her duodenum, her small intestine was swollen, was edematous because of the pancreatitis. But having reviewed her imaging beforehand, I felt that it was, uh, not so swollen to prohibit the procedure. The procedure went smoothly. We were able to get inside her bile duct fairly quickly and lo and behold, she had a stone that was wedged inside her bile duct. And it was wedged in there so so tightly that our usual accessories to get around the stone and fish it out or pull it out weren't going to be effective. And so when I go into a procedure, I like to go in not only with plan A and B, but also C, D, E, and F and maybe more. And so sure enough we had to employ those those plans uh because of the nature of her case. And so we used uh what's called a cholangioscope, a scope within a scope to go inside her bile duct with a with a video camera. We found the stone given its location, we um were concerned about using something called electrohydraulic lithotripsy or EHL. Instead we had to use a spy basket is what it's called. And we were able to get the stone inside the basket using this baby scope, if you will. However, the stone was so hard and because of the size of the bile duct, we couldn't pull it out. That's happened to me a few times in the last decade and fortunately I've trained with some of the giants in the field across the country and so I have a few tricks up my sleeve. In this case we had to actually cut the basket wire and then go in with a different accessory, balloon dilate the bile duct, and then bring the stone with the that was trapped inside the basket out as an ensemble. And after doing so we were tremendously pleased. We were able to essentially resolve this young lady's issue. She woke up in no pain uh to um our delight and uh in 24 hours she was home with normalizing blood tests, no pain, and, um, really no sequela to to worry about. She was able to get back to her baby.
