University of Texas Rio Grande Valley at Doctors Hospital at Renaissance Edinburg, TX, United States
Mohammed Shakhatreh, MD, Ans Albustamy, MD, Lyla Saeed, MD, Asif Zamir, MD, FACG University of Texas Rio Grande Valley at Doctors Hospital at Renaissance, Edinburg, TX
Introduction: Benign biliary strictures are common and may occur after chronic pancreatitis, primary sclerosing cholangitis and after hepato-biliary surgery. Strictures may also sometimes cause duct kinking, which can be difficult to manage. Although endoscopic treatment is the mainstay of therapy for benign biliary strictures, duct kinking presents a separate challenge. In this case report a management approach for a complicated bile duct stricture, causing significant duct kinking.
Case Description/Methods: A 78-year-old man with a history of recurrent pancreatitis complicated by distal biliary stricture, requiring serial bile duct stenting, presented to the ED for progressive jaundice, right upper quadrant pain, hematochezia and melena. Laboratory findings with AST 174 IU/L, ALT 136 IU/L, and an alkaline phosphatase level of 900 IU/L with total bilirubin of 16.7 mg/dL. CT abdomen and pelvis with moderate intrahepatic biliary ducts dilatation with pneumobilia. He was scheduled for EGD and ERCP. EGD revealed duodenal varices. During ERCP, previously placed stents were removed, and an occlusion cholangiogram revealed a dilated duct with a stricture, causing significant duct kinking. A plastic stent was then deployed with good drainage of contrast . After ERCP the patient’s liver enzymes continued to trend upwards, with total bilirubin reaching over 25 mg/dL. MRCP showed mildly dilated intrahepatic ducts. Repeat ERCP demonstrated massive intra and extra hepatic biliary dilation with common bile duct kinking. The plastic stent was removed and replaced with a 10F X 80 mm fully covered, expandable metal stent, deployed across the stricture. After stent placement, liver enzymes and bilirubin began to trend down. The biliary stent was maintained for several years and removed with repeat cholangiogram demonstrating resolution of the stricture.
Discussion: This patient presented with a distal biliary stricture causing significant duct kinking, requiring serial stenting. Plastic biliary stents, with as many as three concurrently placed stents failed to resolve the bend of the duct and themselves were kinked after placement. The long-term use of fully covered metal stents offers a definitive solution in the management of patients with kinking of the bile duct.
Figure: a. ERCP demonstrating significant kinking of the common bile duct. b. Repeat ERCP with resolution of the common bile duct kink after fully covered metal stent deployment
Mohammed Shakhatreh indicated no relevant financial relationships.
Ans Albustamy indicated no relevant financial relationships.
Lyla Saeed indicated no relevant financial relationships.
Asif Zamir indicated no relevant financial relationships.
Mohammed Shakhatreh, MD, Ans Albustamy, MD, Lyla Saeed, MD, Asif Zamir, MD, FACG. P1093 - Kinked CBD Causing Obstructive Jaundice in a Patient With Biliary Stricture: A Case Report, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.