Abhinav Goyal, MD1, Daniel J. Sher, MD2
1Albert Einstein Medical Center, Philadelphia, PA; 2Philadelphia Gastroenterology Consultants, Philadelphia, PA
Introduction: Biliary stent complications are not rare but we present a very rare complication of biliary stent.
Case Description/Methods: 64 year old male with hypertension, diabetes mellitus, coronary artery disease, chronic thrombocytopenia, and orthotopic liver transplant six months prior to presentation for alcoholic cirrhosis was transferred to our center from an outside hospital. He was admitted with fever, nausea, and shortness of breath for 4 days. On arrival, his heart rate was 105/min, and blood pressure 141/88 mm Hg, oral temperature 36.8°C. Physical exam was unremarkable. Total and direct bilirubin were newly elevated to 2.7 and 2.0 mg/dL respectively from 1 and 0.5 mg/dL 10 days ago. WBC was 6.4 x 103/mcL. Gram negative rods were detected in cultures drawn at outside hospital. Due to these findings abdominal ultrasound was done which showed a well positioned pediatric feeding tube inside the bile duct placed at time of transplant to maintain anastomotic patency. There was lack of pneumobilia and progressive extrahepatic biliary ductal dilation. Due to a concern for cholangitis from blocked biliary tube an ERCP was recommended. During ERCP, feeding tube was visualized at ampulla and removed. Biliary cannulation was achieved with wire and sphincterotomy performed. A 1.5 cm anastomotic stricture was seen with ductal dilation proximal and distal to it. A 7 French and 9cm plastic biliary stent was placed across the stricture. Patient improved symptomatically and bilirubin trended down over next 3 days. On fourth day, he developed sudden onset diffuse abdominal pain which was exacerbated by minimal movement. No rebound tenderness or rigidity was noted. He was tachycardic to 112 beats/min. Due to this a stat CT of abdomen/pelvis was done without contrast. Biliary stent was seen to be extending through the contralateral wall of the duodenum, terminating into peritoneal fat with increase in intra-abdominal free fluid. No free air was seen. He was immediately taken to OR for an omental patch repair of the duodenum and peritoneal washout revealed bilious fluid in the peritoneum. Pt had a slow recovery and was discharged to skilled nursing facility fourteen days after the surgery.
Discussion: We present a rare but important early complication of biliary stent placement that needs to be recognized promptly to reduce morbidity and mortality. There are very few cases described in literature and most stent related perforation occured between 5 days and 2 weeks post placement.
Citation: Abhinav Goyal, MD; Daniel J. Sher, MD. P0103 - CASE OF AN UNUSUAL COMPLICATION OF A BILIARY STENT. Program No. P0103. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.