Dae Won Park, et al.. 1,2 POC (electrohydraulic lithotripsy, EHL) 1. 증례 , 64, 18, 140/80 mmhg... 4,400/mm³, 10.8 g/dl, 232,000/mm³. 131

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1 Case Report The Korean Journal of Pancreas and Biliary Tract 2015;20: pissn eissn 경구담도내시경후발생한간내담도천공의증 1 예 광주기독병원소화기내과 박대원 박상욱 김두진 유경완 이금수 김종택 서석호 이승현 A Case of Suspected Intrahepatic Bile Duct Perforation after Direct Peroral Cholangioscopy Dae Won Park, Sang Wook Park, Du Jin Kim, Kyoung Wan You, Geum Soo Lee, Jong Taek Kim, Seok Ho Seo, Seung Hyun Lee Divison of Gastroenterology, Department of Internal Medicine, GwangJu Christian Hospital, Gwangju, Korea Direct peroral cholangioscopy (POC) which permits direct visualization of the biliary tree has recently gained widespread clinical use for diagnosis and treatment of various pancreatobiliary diseases. But, there is currently little reliable data on evaluating the complications of POC. POC is associated with complications such as pancreatitis, cholangitis, hemorrhage, rarely air embolism, and ductal perforation. The incidence of complication during POC is %. However, pneumoperitoneum due to intrahepatic bile duct perforation after POC has not yet been reported in Korea. We report a case of pneumoperitoneum after POC which has been successfully managed with endoscopic nasobiliary drainage and antibiotics. Keywords: Peroral cholangioscopy, Pneumoperitoneum, Bile duct perforation, Common bile duct stone, Electrohydraulic lithotripsy Received Feb. 27, 2015 Revised May. 20, 2015 Accepted May. 21, 2015 Corresponding author : Sang Wook Park Divison of Gastroenterology, Department of Internal Medicine, Gwangju Christian Hospital, 37, Yangnim-ro, Nam-gu, Gwangju , Korea Tel Fax ; This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright 2015 by The Korean Journal of Pancreas and Biliary Tract 서론 (peroral cholangioscopy, POC). (motherbaby duodenoscope) POC, (ultra-slim upper endoscope). direct POC... POC, 146 Copyright 2015 by Korean Pancreatobiliary Association

2 Dae Won Park, et al.. 1,2 POC (electrohydraulic lithotripsy, EHL) 1. 증례 , 64, 18, 140/80 mmhg... 4,400/mm³, 10.8 g/dl, 232,000/mm³. 131 IU/L, 210 IU/L, 669 IU/L, 672 IU/L, 1.3 mg/dl, 77 IU/L, 45.7 IU/L. (computed tomography, CT) (Fig. 1A). (percutaneous transhepatic gallbladder biliary drainage, PTGBD). (endoscopic retrogradecholangiopancreatography, ERCP) 18 mm 15 mm (Fig. 1B). (endoscopic papillary large balloon dilation, EPLBD). POC. EHL (Fig. 2). EHL. A B Fig. 1. (A) Abdominal computed tomography shows multiple common bile duct stones (white arrow), common bile duct and intrahepatic bile duct dilation, and marked gall bladder distension. (B) Endoscopic retrograde cholangiogram shows dilation of the common bile duct with large filling defect (black arrow). 147

3 Suspected Intrahepatic Bile Duct Perforation after Direct Peroral Cholangioscopy 1 X- (Fig. 3A). CT, (Fig. 3B, C). ERCP (endoscopic nasobiliary drainage, ENBD). 3 CT ERCP. 고찰 1970 (percutaneous transhepatic cholangioscopy, PTCS) POC. 3,4 (mother-baby endoscopy system) (mother scope) (baby scope). A B C Fig. 2. (A) Direct peroral cholangioscopy shows a impacted stone inside the common bile duct. (B) After electrohydraulic lithotripsy, impacted stone is fragmented and removed with a basket. (C) Fluoroscopy shows the ultraslim upper endoscope in the distal common bile duct with the impacted emergent lithotriptor. A B C Fig. 3. (A) Chest X -ray finding after endoscopic retrograde cholangiography and direct peroral cholangioscopy. Free air is noted in the subdiaphragmic area. (B) Abdominal computed tomography taken on the day after endoscopy shows pneumobilia and perihepatic free air (white arrow). (C) No free air is seen in retroperitoneum around duodenum and common bile duct

4 Dae Won Park, et al.,. 5 SpyGlass. 5-6 mm, 2.0 mm. 6. 5,7-9. Meves POC 87% 81%. 12% 7, 1, 2. POC,. 10,11,., Parsi ,. EHL. 1% ,., 50 cc EHL.. POC. 149

5 Suspected Intrahepatic Bile Duct Perforation after Direct Peroral Cholangioscopy 요약 POC. POC EHL. POC. 국문색인 : 경구담도내시경, 기복증, 담관천공, 총담관결석, 전기수압쇄석술 Conflicts of Interest The author has no conflict to disclose. REFERENCES 1. Moon JH, Choi HJ. The role of direct peroral cholangioscopy using an ultraslim endoscope for biliary lesions: indications, limitations, and complications. Clin Endosc 2013;46: Meves V, Ell C, Pohl J. Efficacy and safety of direct transnasal cholangioscopy with standard ultraslim endoscopes: results of a large cohort study. Gastrointest Endosc 2014;79: Seo DW, Lee SK, Park JS, et al. Cholangioscopic findings of various bile duct tumors according to histology. Korean J Gastrointest Endosc 2000;21: Nimura Y, Shionoya S, Hayakawa N, Kamiya J, Kondo S, Yasui A. Value of percutaneous transhepatic cholangioscopy (PTCS). Surg Endosc 1988;2: Larghi A, Waxman I. Endoscopic direct cholangioscopy by using an ultra-slim upper endoscope: a feasibility study. Gastrointest Endosc 2006;63: Sola-Vera J, Uceda F, Cuesta R, Vázquez N. Direct peroral cholangioscopy using an ultrathin endoscope: making technique easier. Rev Esp Enferm Dig 2014;106: Itoi T, Reddy DN, Sofuni A, et al. Clinical evaluation of a prototype multi-bending peroral direct cholangioscope. Dig Endosc 2014;26: Lee YN, Moon JH, Choi HJ, et al. Direct peroral cholangioscopy using an ultraslim upper endoscope for management of residual stones after mechanical lithotripsy for retained common bile duct stones. Endoscopy 2012;44: Lee DK, Jahng JH. Alternative methods in the endoscopic management of difficult common bile duct stones. Dig Endosc 2010;22(suppl): Albert JG, Friedrich-Rust M, Elhendawy M, Trojan J, Zeuzem S, Sarrazin C. Peroral cholangioscopy for diagnosis and therapy of biliary tract disease using an ultra-slim gastroscope. Endoscopy 2011;43: Efthymiou M, Raftopoulos S, Antonio Chirinos J, May GR. Air embolism complicated by left hemiparesis after direct cholangioscopy with an intraductal balloon anchoring system. Gastrointest Endosc 2012;75: Parsi MA, Stevens T, Vargo JJ. Diagnostic and therapeutic direct peroral cholangioscopy using an intraductal anchoring balloon. World J Gastroenterol 2012;18: Waxman I, Dillon T, Chmura K, et al. Feasibility of a novel system for intraductal balloon-anchored direct peroral cholangioscopy and endotherapy with an ultraslim endoscope (with videos). Gastrointest Endosc 2010;72: Arya N, Nelles SE, Haber GB, Kim YI, Kortan PK. Electrohydraulic lithotripsy in 111 patients: a safe and effective therapy for difficult bile duct stones. Am J Gastroenterol 2004;99: Cameron JL, Cameron AM. Current surgical therapy: Expert consultonline. 11th ed. p , Elsevier Health Sciences,

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