We present the case of a 76-year-old male with morbid obesity who was transferred to our center for severe (grade III) acute cholangitis complicated by renal dysfunction. Preprocedrual CT scan demonstrated global extrahepatic and intrahepatic dilation of the bile ducts without a clear cause

Emergency ERCP was indicated for biliary decompression in this setting. However, multiple attempts at selective biliary cannulation—including wire-guided and contrast-assisted techniques—were unsuccessful. A precut septotomy using a pancreatic guidewire failed to achieve deep cannulation, and subsequent needle-knife papillotomy did not permit guidewire passage into the common bile duct, raising suspicion of an impacted stone in the distal portion of the common bile duct.

In this emergency setting, a EUS-guided biliary access was attempted. Under endoscopic ultrasound, the distal common bile duct was punctured from the duodenum and an anterograde guidewire was successfully advanced through the papilla; however, retrograde cannulation over the wire could not be achieved due to guidewire being damaged through shearingduring needle-guided access. 

Finally, to secure biliary drainage and allow closure of the duodenal access point, an EUS-guided hepaticogastrostomy was performed. Anterograde cholangiography demonstrated marked dilation of the intrahepatic ducts with a hilar obstruction,  due to a tightly impacted stone. A transhepatic guidewire was advanced distally into the duodenum, permitting transpapillary deployment of a 4-cm fully covered self-expandable metal stent (SEMS). A 15/7 Fr double-pigtail stent was subsequently placed across the hepaticogastrostomy tract, obtaining effective drainage of purulent bile into the stomach.

48 hours after the procedure, the patient developed melena, hypotension, and altered mental status. Angio-CT revealed correct positioning of the stents and inflammatory changes suggestive of acute pancreatitis. Upper endoscopy identified a large duodenal clot adherent to the biliary SEMS (Forrest IIb). Hemostasis was achieved by placing two clips at the margin of the sphincterotomy and applying hemostatic gel. The patient’s condition gradually improved with supportive care, demonstrated by normalization of renal parameters and inflammatory markers and the patient was discharged 5 days after the initial procedure, with scheduled follow-up at 1 month 

Conclusion : This case underscores the critical role of EUS-guided biliary drainage (EUS-BD) as a life-saving rescue modality when ERCP fails, particularly in patients with severe cholangitis and challenging anatomy. EUS-BD offers a minimally invasive, highly effective alternative for urgent biliary decompression, enabling timely source control and improving clinical outcomes in high-risk patients.