Kevin V. Houston, MD1, Byung S. Yoo, MD2, Parth J. Parekh, MD2 1VCU Health System, Richmond, VA; 2Eastern Virginia Medical School, Norfolk, VA
Introduction: Malignant duodenal strictures and placement of uncovered, metal duodenal stents can affect biliary drainage and be challenging cases for endoscopists if biliary complications arise. Choledochoduodenostomy (CDD) and cholecystoduodenostomy (CCD) are procedures used for biliary diversion or to gain access for debris or stone removal. We present a case of recurrent cholangitis after CDD, requiring multiple follow-up endoscopic interventions.
Case Description/Methods: A 47-year-old female with a history of malignant duodenal stricture presented with fever, nausea, and right upper quadrant pain. Medical history included an uncovered, metal duodenal stent with tissue in-growth and granulation at the level of the papilla. This caused biliary obstruction and required endoscopic intervention. First, due to a persistently dilated biliary tree and development of a hepatic abscess, a CDD was created for biliary decompression. She later presented with cholangitis and choledocholithiasis. As the previous stent dislodged, a repeat CDD was attempted, but could not be created due to biliary fibrosis. Instead, a CCD was created as an alternate site for drainage, assuming the cystic duct was patent. She improved clinically after each procedure.
This admission, her labs were a WBC of 17.6 K/μL, AST 90 U/L, ALT 76 U/L, total bilirubin 1.9 µmol/L, direct bilirubin 1.7 µmol/L, alkaline phosphatase 503 U/L and lipase 362 U/L. CT imaging showed pneumobilia, intrahepatic biliary duct dilation, and a dilated common bile duct (CBD). She was diagnosed with cholangitis from presumed choledocholithiasis and a CDD with electrohydraulic lithotripsy (EHL) was planned. Endosonographically, the CBD was found dilated with distal stones present (Figure 1A). A CDD was successfully created (Figure 1B) and cholangioscopy revealed several pigmented stones (Figure 1C). EHL was then performed with the fragments evacuated. Follow-up imaging showed CDD and CCD in place (Figure 1D and 1E) and a diminishing of her hepatic abscess. She has had no complications or symptom recurrence to date.
Discussion: We report a case of an uncovered, metal duodenal stent causing biliary obstruction and the development of recurrent cholangitis and choledocholithiasis. To our knowledge, this is the first creation of both a CDD and CCD in the same patient for biliary decompression. Recurrence of symptoms required an additional CDD with EHL to be performed. Experienced endoscopists should consider these procedures for challenging cases of biliary obstruction.
Figure: Figure 1A: Endosonographic ultrasound of the common bile duct measuring 19.4 mm (blue line) and stone present (red arrow). Figure 1B: Choledochoduodenostomy lumen-apposing metal stent. Figure 1C: Cholangioscopy revealing a pigmented stone (red arrow) in the distal common bile duct. Figure 1D: Post-procedure CT abdomen showing a cholecystoduodenostomy stent (red arrow). Figure 1E: Post-procedure CT abdomen showing a choledochoduodenostomy stent (red arrow) and a long duodenal stent (blue arrow).
Kevin Houston indicated no relevant financial relationships.
Byung Yoo indicated no relevant financial relationships.
Parth Parekh indicated no relevant financial relationships.
Kevin V. Houston, MD1, Byung S. Yoo, MD2, Parth J. Parekh, MD2. P0099 - One Plug, Two Stents, Three Procedures: Uncovered Duodenal Stent Causing Biliary Obstruction and the Creation of a Choledochoduodenostomy and Cholecystoduodenostomy, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.