Shinban Liu, DO, David Parizh, DO, Vadim Meytes, DO, Mohan Kilaru, MD. NYU Langone Hospital – Brooklyn
Introduction: Acute cholangitis is an ascending infection of the biliary tree secondary to obstruction and can be severe if proper intervention and treatment are not performed in a timely fashion. The most common management of cholangitis with ductal obstruction due to choledocholithiasis is intravenous hydration, empiric antibiotic therapy, endoscopic retrograde cholangiopancreatogram (ERCP) with sphincterotomy and stone extraction with or without stent placement, followed by a delayed laparoscopic cholecystectomy. We present the case of a patient with blood clot obstruction of a common bile duct (CBD) stent after ERCP with sphincterotomy and stone extraction.
Case Presentation: A 58 year old male presented to the emergency department with jaundice, right upper quadrant abdominal pain, truncal pruritis, nausea, vomiting, and fever. Biochemical analyses and liver profile demonstrated an elevated white blood cell count, hyperbilirubinemia, and elevated liver enzymes consistent with cholestasis. Biliary ultrasound demonstrated multiple gallstones and dilation of the CBD with a distal obstructing calculus. He proceeded to ERCP where biliary cannulation was achieved, sphincterotomy performed, and a large amount of sludge and pus was drained. An 8mm stone was removed from the CBD by balloon sweep with completion cholangiogram demonstrating no filling defects. A stent was then placed in the CBD with adequate flow. Following the procedure, the patient continued to have increasing hyperbilirubinemia. A repeat ERCP revealed a large blood clot and continued bleeding at the previous sphincterotomy that resolved with epinephrine injection. The former stent was visualized in the proper position, removed with a snare, and found to be fully occluded with blood clots. After retrieval of additional clots, a new stent was placed with adequate return of bile. The patient recovered with resolution of his symptoms and hyperbilirubinemia with laparoscopic cholecystectomy.
Discussion: Cholangitis is characterized by Charcot’s triad of right upper quadrant abdominal pain, fever, and jaundice due to an ascending bacterial infection of the biliary tree coinciding with obstruction of biliary flow most commonly from gallstones. Cholangiography via ERCP with associated sphincterotomy, stone extraction, and stenting is both diagnostic and therapeutic. While debated by endoscopists, stent placement has shown to reduce recurrent biliary complications, decrease length of hospital stay, and lessen morbidity. Although pancreatitis is the most common cause of hyperbilirubinemia post-ERCP, stent occlusion secondary to stones or blood clots should be considered to effectively treat patients. Proper hemostasis is important in any procedure and close patient follow-up should be performed to prevent further complications.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 85001
Program Number: P100
Presentation Session: iPoster Session (Non CME)
Presentation Type: Poster