Authors C. SALEM (1), C. MUSALA (2), G. RASSCHAERT (2), L. DUEZ (2), T. SERSTE (2), P. EISENDRATH (2) / [1] CHU Saint-Pierre, Brussels, Belgium, GASTROENTEROLOGY, [2] CHU Saint-Pierre, Brussels, Belgium, Hepato-Gastro-enterologie Introduction Chronic morphine abuse has been reported as a rare cause of concomitant dilation of both pancreatic (PD) and common bile duct (CBD), known as the double duct sign (1,2,3). Endoscopic ultrasound (EUS) findings of this rare entity have been occasionally reported (4). We report a 59-year-old man recently diagnosed with double duct sign, with a history of chronic opioid abuse evaluated for episodes of abdominal pain and general status alteration. The patient has a history of bypass surgery, that made the diagnosis more challenging. In order to rule out malignancy, EUS-directed trans gastric intervention (EDGI) was performed to enable pancreatic head EUS and potential ERCP. Case report This is a new report of a 59 year old man admitted to the hospital for several episodes of abdominal pain and general status alteration in May 2019. The patient is a chronic morphine consumer with an average of 300mg per day in a context of fibromyalgia. He was operated of a gastric bypass for morbid obesity in 2017. The patient has no history of alcohol and tobacco consumption. An earlier Computed Tomography scan (CT scan) from two month ago, revealed biliary and pancreatic duct dilation (10mm and 9 mm respectively). The patient didn’t come back for planified workup. During current hospitalization, new CT scan and Magnetic resonance cholangiography (MRCP) were performed and revealed worsening duct dilation (17mm and 19mm respectively) without evidence of an obstructive tumor or lithiasis. Lab analysis showed a new cholestasis onset: alkaline phosphatase 155 U/L, GGT 72 U/L, serum bilirubin of 0.2 mg/dL, aspartate aminotransferase of 20 U/L and alanine aminotransferase of 24 U/L. Endoscopic ultrasound (EUS) revealed simultaneous dilatation of the CBD and PD (double duct sign) with anechoic lumens of both the ducts. Pancreatic and periampullary region exploration was limited due to post bypass anatomy. After a multidisciplinary discussion and in the concern of excluding a periampullary tumor, it was decided to perform an EUS trough an artificial gastro-gastric anastomosis, eventually combined with a biliary sphincterotomy and stenting. At the first stage, using a therapeutic echo-endoscope, a lumen apposing metal stent (LAMS) of 20mm diameter with electrocautery delivery system was inserted between the proximal jejunum and the excluded stomach. The trans-anastomotic EUS was perform 28 days after the LAMS implantation. It revealed biliary and pancreatic duct dilation up to the papilla, in a context of pancreas divisum with some stigmas of chronic pancreatitis, absence of tumor or other cause of obstruction. Both procedures were concluded without any complications. ERCP wasn’t finally realized given the favorable evolution of cholestasis. These results and spontaneous evolution led us to a suspicious diagnosis of chronic sphincter dysfunction. Patient was readmitted to our unit 35 days post procedure, for prosthesis removal. He had no symptoms and stable liver function test. He regained 6 kilos of weight since his last admission with an actual BMI of 23.5. The Axios prothesis was removed under general anesthesia and a double pigtail was inserted without particular difficulties. Discussion Several studies showed that chronic opiate use may responsible of common bile duct dilation by increasing sphincter of Oddi tonicity and resulting in secondary SOD (1,2,3,5). EUS is an important part the work-up in case of bile duct dilation to exclude small malignant lesion in the ampullary area (6). Beside the report of new case with suspected morphine abuse related double duct sign, this case illustrates also the problem of access to pancreatic head in a modified anatomy. EDGI is a recent technique to gain access to the excluded stomach in order to facilitate conventional pancreatic head EUS exploration and ERCP (6,7). Previous case series showed that EDGI is associated with high technical and clinical success, and with insignificant risk of short and long term adverse events (6,7). Opiate abuse is an uncommon cause of SOD and a prolonged history of opiate addiction must be sought in patients with unexplained biliary dilatation or dual duct after adequate workup to evaluate potential underlying pathologies (5,6).
