VideoGIE
flap of muscle layer (Fig. 1C). The defect was too large for
simple closure by using clips. Therefore, we decided
to use the endoloop-clips technique. The endoloop was
delivered by hanging a clip. Consequently, we anchored
clips on both sides of the endoloop, and the defect
was repaired by tightening the endoloop, followed by
clipping the space between the flap and the surrounding
mucosa (Figs. 1D-F; Video 1, available online at
www.giejournal.org). The postoperative course was
uncomplicated, and the patient was discharged 5 days
after the procedure.
AIDS cholangiopathy visualized by single-operator
cholangioscopy
Figure 1. Endoscopic retrograde cholangiographic view demonstrating a focal stricture of common hepatic duct with upstream dilatation.
A 51-year-old woman with AIDS (CD4 count 150/mL,
HIV-1 RNA copies 143) and a history of multiple opportu-
nistic infections presented to our hospital with neutro-
penic fever and an absolute neutrophil count of 513/mL.
Her cultures were negative for infection. Liver chemistry
studies revealed an elevated alkaline phosphatase of
1524 U/L, alanine aminotransferase 103 U/L, aspartate
aminotransferase 90 U/L, and total bilirubin 0.7 mg/dL.
MRCP showed a focal narrowing of the common hepatic
This video can be viewed directly
from the GIE website or by using
the QR code and your mobile de-
vice. Download a free QR code
scanner by searching “QR Scanner”
in your mobile device’s app store.
www.giejournal.org
DISCLOSURE
All authors disclosed no financial relationships rele-
vant to this publication.
Motohiko Kato, MD, PhD, Toshio Uraoka, MD, PhD,
Michiko Wada, MD, Shigeo Banno, MD, Satoshi
Kinoshita, MD, Kaoru Takabayashi, MD, PhD, Masahiro
Kikuchi, MD, PhD, Department of Gastroenterology,
National Hospital Organization, Tokyo Medical Center, Tokyo,
Japan
http://dx.doi.org/10.1016/j.gie.2015.12.023
duct with mild dilatation of the intrahepatic bile ducts.
Neutropenia was treated with a granulocyte colony stimu-
lating factor injection, and ERCP was performed. A cholan-
giogram revealed a dilated biliary confluence, proximal
common hepatic duct (CHD) of 10 mm, and a 4-mm stric-
ture of the mid-CHD. The common bile duct appeared
normal (Fig. 1). Bile aspirate was obtained for
microbiologic analysis, and biliary sphincterotomy was
performed. Single-operator cholangioscopy revealed a
fibrotic-appearing stricture of the CHD with pseudodiverti-
cula. The distal CHD contained multiple nonobstructing
rings. Multiple cholangioscopy-directed biopsy specimens
were obtained of the CHD stricture (Video 1, available
online at www.giejournal.org). A plastic stent was placed.
The results of bile analysis for microsporidia,
Cryptosporidium oocysts, and ova and parasites were
Volume 83, No. 6 : 2016 GASTROINTESTINAL ENDOSCOPY 1283
VideoGIE

negative. Pathologic analysis of the stricture showed
unremarkable fibrous tissue lined by benign ductal
epithelium. The patient remained afebrile after ERCP,
with subsequent improvement in cholestasis.
DISCLOSURE
All authors disclosed no financial relationships rele-
vant to this publication.
Robert J. Sealock, MD, Department of Gastroenterology
and Hepatology, Baylor College of Medicine, Houston, Texas,
USA, Kalpesh Patel, MD, Department of Gastroenterology
and Hepatology, Baylor College of Medicine, Houston, Texas,
USA
http://dx.doi.org/10.1016/j.gie.2015.11.042

Bedside EUS-guided treatment in a critically ill patient with

acute cholecystitis

Figure 1. Sequence of Hot AXIOS stent Boston Scientific, Marlborough, Mass placement: A, The catheter is energized (using pure-cut setting) and advanced
through the duodenal wall into the gallbladder. B, The distal flange of the covered metal stent is deployed. C, The stent is carefully retracted, and the distal
flange is positioned against the lumen wall; the black catheter shaft marker is visible on the endoscopic view. D, The proximal flange is deployed.

A 49-year-old man was admitted to the intensive care

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from the GIE website or by using
the QR code and your mobile de-
vice. Download a free QR code
scanner by searching “QR Scanner”
in your mobile device’s app store.
unit for acute respiratory distress syndrome due to H1N1
influenza infection. He developed acute lithiasic cholecys-
titis with septic shock. Because of the critical clinical con-
ditions, bedside EUS-guided gallbladder drainage was
considered the best choice of treatment.
The drainage was done from the duodenal bulb, which
was a favorable position. The gallbladder was directly

1284 GASTROINTESTINAL ENDOSCOPY Volume 83, No. 6 : 2016 www.giejournal.org