P2335 - (Octreo)tides Have Turned: EUS-Guided Cholecystoduodenostomy With Gallstone Extraction in a Patient With Recurrent Cholangitis and Biliary Colic Due to Chronic Octreotide for Metastatic Neuroendocrine Tumor

Lawrence Leung, MD, MPH¹, Pradeep Koripella, MD¹, Christopher Hamerski, MD¹, Kunal Karia, MD¹, Marcia Leung, MD¹, Jeffrey Lee, MD, MPH², Suraj Gupta, MD^1
1Kaiser Permanente, San Francisco, CA; ²Kaiser Permanente San Francisco Medical Center, San Francisco, CA

Introduction: Chronic octreotide is a risk factor for the development of gallstones (GS). Percutaneous and endoscopic management have been utilized in patients who are poor surgical candidates, usually to treat acute complications such as cholecystitis. We present a case of EUS-guided cholecystoduodenostomy (EUS-CD) to extract GS in a patient with biliary colic and recurrent cholangitis in the setting of chronic octreotide associated GS disease, where gallbladder (GB) decompression alone would not be sufficient to alleviate his symptoms or risk for cholangitis.

Case Description/Methods: A 74-year-old man with a history of metastatic pancreatic neuroendocrine tumor treated with distal pancreatectomy, left hepatectomy, transverse colectomy with colostomy, radiation therapy and extended suppressive octreotide use, was found to have innumerable GS after presenting with cholangitis and being treated with ERCP and sphincterotomy. He was deemed a poor surgical candidate due to his numerous abdominal surgeries, radiation and transverse colostomy overlying the right upper quadrant, which would need to be reversed for surgical cholecystectomy. We opted to proceed with EUS-CD with stone extraction to reduce his risk of cholangitis and to alleviate his symptoms of biliary colic. Assessment with MRI showed greater than 200 GS impacted in the GB. EUS-CD was performed, with placement of a 10mm x 10mm lumen apposing metal stent (LAMS). After allowing the tract to mature and upsizing to a 10mm x 15mm LAMS (Figure A), over 200 GS (Figure B) were extracted over 3 sessions by electrohydraulic lithotripsy, basket and balloon sweep, resulting in complete removal of all GS from the GB, confirmed under fluoroscopy with contrast and then MRCP (Figure C). Ursodiol was added to reduce the recurrence of GS. Six months later, he continues to do well without recurrence of cholangitis or biliary colic.

Discussion: In rare cases of chronic octreotide use, GS burden can be high and lead to biliary colic, cholangitis and cholecystitis. The mechanism of octreotide-GS formation is thought to be attributed to GB stasis and modification of bile composition. For those who are poor surgical candidates after initial decompression, EUS-CD offers an option for stone extraction. Although EUS-guided GB drainage is reported frequently in literature for acute cholecystitis, EUS-CD for stone extraction is relatively novel with very few documented cases. Our case highlights the successful option for endoscopic GS management.



Disclosures:


Lawrence Leung, MD, MPH¹, Pradeep Koripella, MD¹, Christopher Hamerski, MD¹, Kunal Karia, MD¹, Marcia Leung, MD¹, Jeffrey Lee, MD, MPH², Suraj Gupta, MD¹. P2335 - (Octreo)tides Have Turned: EUS-Guided Cholecystoduodenostomy With Gallstone Extraction in a Patient With Recurrent Cholangitis and Biliary Colic Due to Chronic Octreotide for Metastatic Neuroendocrine Tumor, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.