What's the next management step for a patient with a duodenal bulb mass, rising Liver Function Tests (LFTs), and a history of cholecystectomy, after a failed Endoscopic Retrograde Cholangiopancreatography (ERCP) attempt?

Management of Duodenal Bulb Mass with Failed ERCP

Percutaneous transhepatic biliary drainage (PTBD) should be performed for biliary decompression in this patient with rising LFTs and failed ERCP due to duodenal bulb mass obstruction. 1

Primary Management Algorithm

Immediate Biliary Decompression Options

When ERCP fails due to inability to pass through a duodenal bulb mass, the management hierarchy is:

• Percutaneous transhepatic biliary drainage (PTBD) is the recommended second-line approach after failed ERCP for biliary decompression, particularly when the papilla is inaccessible due to duodenal obstruction 1

• EUS-guided biliary drainage (EUS-BD) is an alternative option if available at an expert center with interventional EUS capabilities, though this requires specialized expertise and multidisciplinary support 1

Why PTBD is Preferred in This Clinical Context

• PTBD is specifically indicated when ERCP fails due to inaccessible papilla or unsuccessful biliary cannulation 1

• The rising LFTs indicate biliary obstruction requiring urgent decompression to prevent cholangitis and further hepatic injury 1

• The duodenal bulb mass creates a mechanical barrier preventing endoscopic access to the ampulla, making PTBD the most practical drainage option 1

PTBD Technical Considerations and Risks

Potential complications include:

• Biliary peritonitis 1
• Hemobilia 1
• Pneumothorax 1
• Hematoma and liver abscesses 1
• Patient discomfort related to external catheter 1

Despite these risks, PTBD provides effective biliary decompression when endoscopic approaches are not feasible 1

Alternative: EUS-Guided Biliary Drainage

If available at an expert center, EUS-BD may be considered as it can achieve biliary drainage when ERCP is not possible due to duodenal stenosis or surgically altered anatomy 1

Requirements for EUS-BD:

• Must be performed at expert centers with facilities and expertise in interventional EUS and advanced ERCP 1

• Requires experienced endoscopists skilled in EUS-FNA, wire manipulation techniques, and stent placement 1

• Multidisciplinary support including interventional radiologist, surgeons, and anesthesiologist is recommended due to higher complication rates (18.9%) compared to standard ERCP 1

• Technical success rate is approximately 76.6% 1

EUS-BD Approach Options:

• Transgastric approach is recommended as the initial approach 1
• Appropriate imaging including MRCP or contrast-enhanced CT should be obtained prior to the procedure 1
• Antibiotic prophylaxis is recommended before EUS-BD 1

Surgical Drainage: Last Resort

Open surgical drainage should only be used when both endoscopic and percutaneous transhepatic drainage are contraindicated or have been unsuccessfully performed 1

• A randomized controlled trial demonstrated that endoscopic nasobiliary drainage plus sphincterotomy had significantly lower morbidity and mortality compared to T-tube drainage under laparotomy in severe acute cholangitis 1

• Surgical intervention carries higher morbidity in the setting of biliary obstruction and should be reserved for cases where less invasive options have failed 1

Concurrent Diagnostic Workup

Tissue Diagnosis of Duodenal Mass

While addressing biliary obstruction, tissue diagnosis of the duodenal bulb mass is essential to guide definitive treatment:

• EUS-guided fine needle aspiration has high sensitivity (84%) and specificity (100%) for tissue diagnosis and can detect lesions missed by other imaging modalities 2

• If EUS-FNA cannot be performed due to technical limitations, CT-guided biopsy or surgical biopsy may be necessary 2

Imaging Assessment

• MRCP or contrast-enhanced CT should be obtained to assess the extent of biliary obstruction, level of obstruction, and characteristics of the duodenal mass 1, 2

• MRCP provides valuable information on biliary anatomy, extent of duct involvement, and can help plan the drainage approach 2

Common Pitfalls to Avoid

• Do not delay biliary decompression while pursuing tissue diagnosis, as rising LFTs indicate progressive biliary obstruction that can lead to cholangitis and hepatic dysfunction 1

• Do not attempt repeated ERCP procedures if the initial attempt clearly demonstrates inability to pass the duodenal mass, as this increases complication risk without benefit 3

• Do not assume normal bilirubin excludes significant biliary obstruction in a post-cholecystectomy patient with rising alkaline phosphatase and transaminases 4, 5

• Ensure antibiotic coverage is initiated if there are any signs of cholangitis (fever, elevated white blood cell count) before attempting drainage procedures 1