St. Luke's University Health Network, Anderson Campus Easton, PA, United States
Award: Presidential Poster Award
Aumi Brahmbhatt, MD1, Krielle Pantino, MD2, Rodrigo Duarte-Chavez, MD3, Manan Brahmbhatt, 4, Loveleen Sidhu, MD5, Kimberly Chaput, DO6 1St. Luke's University Health Network, Anderson Campus, Easton, PA; 2St. Luke's University Health Network, Easton, PA; 3St. Luke's University Health Network, Bethlehem, PA; 4Medical University of Lublin, Lublin, Lubelskie, Poland; 5St. Luke's University Hospital, Bethlehem, PA; 6St. Luke's University Health Network, Fountain Hill, PA
Introduction: A migrating surgical clip is a rare event, pancreatitis secondary to migrating surgical clip is an even rarer occurrence.
Case Description/Methods: A 43-year-old female with history of T2DM, lupus, prior appendectomy, gastric bypass, laparoscopic cholecystectomy 20 years ago, presented with RUQ pain for 4 days, radiating to her back with associated nausea and vomiting. Of note, she was punched in the abdomen 8 days prior to admission. On examination she had RUQ tenderness to palpation and no rebound. Laboratory evaluation showed AST 654, ALT 991, ALP 985, T.bili 2.8. CT abdomen/pelvis showed migration of the surgical clip from previous cholecystectomy, from the gallbladder fossa to the intrapancreatic CBD. Infectious hepatitis and autoimmune pancreatitis panels were negative. The day after, LFTs were downtrending. However, her pain worsened, and a repeat CT showed peripancreatic edema and CBD dilatation of 11mm, and the surgical clip was now in the descending duodenum near the CBD orifice. This was followed by MRCP in which the clip was no longer apparent and the CBD had decreased to 7mm. A KUB was done to follow the clip radiographically the day after and the clip was no longer visible. No further intervention was deemed necessary, and she was managed with aggressive IV fluids and symptom control, eventually being discharged home.
Discussion: The first case of surgical-clip migration into the CBD after cholecystectomy was reported in 1979. By now, this is a familiar concept, though uncommonly seen clinically. Common presentations are obstructive jaundice, cholangitis, biliary colic, and acute pancreatitis. The mechanism is unknown, though there is a direct association with the number of surgical clips used during the procedure. The prevalent thought is that necrosis of the cystic duct dislodges the clip. Improper clipping of the cystic duct leads to partial patency, forming a biloma. Over time, the biloma leads to surrounding tissue necrosis due to a chronic inflammatory process, and as the tissue necrotizes, the clip migrates. This effect is potentiated by increased intra-abdominal pressure and a short cystic stump, and the clip itself may serve as an instigator here as a foreign body.
We report a middle-aged female presenting with pancreatitis following abdominal trauma with migration of surgical clip into the CBD 20 years after laparoscopic cholecystectomy. We hypothesize that her abdominal trauma dislodged the surgical clip, provoking acute pancreatitis.
Figure: 1) CT Abdomen pelvis, coronal view, clip seen in the intrapancreatic CBD 2) CT Abdomen pelvis, axial view, clip seen in the intrapancreatic CBD 3) CT Abdomen pelvis, coronal view, clip seen within the small bowel, adjacent to the CBD orifice 4) CT Abdomen pelvis, axiall view, clip seen within the small bowel, adjacent to the CBD orifice 5) MRCP showing the distal CBD, the metallic clip is no longer visualized at the ampullary region 6) KUB of the abdomen, the surgical clip is not visualized at the right paralumbar area
Aumi Brahmbhatt indicated no relevant financial relationships.
Krielle Pantino indicated no relevant financial relationships.
Rodrigo Duarte-Chavez indicated no relevant financial relationships.
Manan Brahmbhatt indicated no relevant financial relationships.
Loveleen Sidhu indicated no relevant financial relationships.
Kimberly Chaput indicated no relevant financial relationships.
Aumi Brahmbhatt, MD1, Krielle Pantino, MD2, Rodrigo Duarte-Chavez, MD3, Manan Brahmbhatt, 4, Loveleen Sidhu, MD5, Kimberly Chaput, DO6. P0056 - The Traveling Surgical Clip and Pancreatitis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.