Detection of mucin-hypersecreting bile duct tumor by direct peroral cholangioscopy.

bile duct tumor is difficult because of ambiguity caused by the abundant mucin secretion and/or by the superficial mucosal spread of the tumor along the bile duct [1]. We report the case of a 77-year-old patient, who initially presented with severe jaundice, right upper abdominal pain, and fever. The endoscopic retrograde cholangiopancreatography (ERCP) demonstrated a large amount of viscous mucin in a dilated bile duct system (●" Fig. 1a,b). A large endoscopic sphincterotomy was initially performed but the mucin could not be completely removed with basket and balloon catheters and a tumor could not be detected. Cholangioscopy by baby– mother techniquewas also unhelpful; suction power and pressure washing were insufficient and devices such as basket catheters are not available for the choledochofiberscope (CHF-BP30, 1.2-mm working channel; Olympus, Tokyo, Japan). It was decided to use an ultrathin upper endoscope (GIF-XP160, outer diameter of 5.9mm, 2.0-mm working channel; Olympus, Tokyo, Japan) to perform direct peroral cholangioscopy (●" Fig. 2). This procedure, first reported in 1977, has since been described with several variations [2–5]. After insertion of a nasal biliary drainage tube (PBD-21Z, 2.35-mm maximum diameter; Olympus, Tokyo, Japan) the ultrathin upper endoscope was advanced beside the drainage tube directly into the bile duct by pushing and pulling in a stepwise manner while twisting the endoscope. Using an endowasher (Aqua:Master; Endo-Technik W. Griesat GmbH, Solingen, Germany) via the working channel of the ultrathin endoscope, it was possible to wash out the mucin from the bile duct and to have a direct view of the tumor (●" Fig. 3). Biopsies confirmed the diagnosis of a mucin-producing bile duct adenoma in the left hepatic lobe. The patient underwent Detection of mucin-hypersecreting bile duct tumor by direct peroral cholangioscopy