Mucin-producing bile duct tumor treated successfully with endoscopic ultrasound-guided hepaticogastrostomy

We report the case of an 82 year-old Japanese man with a history of multiple heart surgeries who presented with nausea and loss of appetite. Laboratory tests showed elevated liver and biliary enzymes. Imaging showed a possible space-occupying lesion within a dilated bile duct. Endoscopic retrograde cholangiography showed an intact ampulla of Vater with a visible mucus-filled orifice presenting a fish-mouth appearance and fluoroscopy showed a possible tumor-causing mild stenosis of the bile duct. Cholangioscopy revealed papillary protrusions in the common bile duct. Pathological evaluation was inconclusive but negative for malignancy. Patient was presumptively diagnosed with intraductal papillary neoplasm of the bile duct. Mucobilia caused repeated migration of metallic biliary stents, requiring numerous endoscopic interventions. Endoscopic ultrasound-guided hepaticogastrostomy was performed, as patient was no longer fit for surgery. All abdominal symptoms resolved and laboratory values normalized. Patient remained symptom-free during 12 months of follow-up.