Clinical Gastroenterology and Hepatology
Volume 8, Issue 3 , Pages e24-e25, March 2010

Surprise Finding at Endoscopic Retrograde Cholangiopancreatography

published online 05 October 2009.

Article Outline

 

A 47-year-old woman was admitted with right upper-quadrant pain, radiating to her back, with nausea and fever. She was known to have had gallstones and had undergone open cholecystectomy 9 years earlier. She developed epilepsy after an intracerebral hemorrhage at the age of 22, for which she was on treatment with phenytoin and carbamazepine, and had mild asthma.

On admission she was afebrile but was tender over the right upper quadrant with a scar consistent with her previous surgery. Her white cell count was increased at 17.9 × 109/L (range, 3.9–11.1) (neutrophils 14.6 × 109/L), with a bilirubin level of 25 μmol/L (range, 1–17), alkaline phosphatase level of 373 IU/L (range, 35–104), alanine transaminase level of 538 IU/L (range, 0–40), and a γ-glutamyl transferase level of 1675 IU/L (range, 5–40). Her amylase level was 60 IU/L (range, 0–100). An ultrasound scan of the liver and biliary system showed a large calculus in the proximal common bile duct (CBD), as well as obstructing calculi at the distal end of the CBD with dilatation to 13 mm.

She underwent endoscopic retrograde cholangiopancreatography. The control film shows 2 clips within the distal CBD (Figure A, arrowhead) that were not present at the end of the procedure. Figure B shows a filling defect, with 2 surgical clips centrally, in the distal CBD (a gallstone formed on a nidus of clips, termed a cat's eye calculus because of its similarity to the feline iris1). At endoscopic retrograde cholangiopancreatography the patient underwent sphincterotomy and 2 stones, the largest was 9 mm, were extracted from the CBD. After the procedure, 2 metal surgical clips (Figure C) were found trapped within the bridge of the duodenoscope. The surrounding stones had crumbled during the procedure.

Migration of surgical clips postcholecystectomy into the CBD is rare; however, there have been increasing numbers of reports in the literature to date. It was first described in 1979 in a case of choledocholithiasis after open cholecystectomy,2 and in 1992 after laparoscopic cholecystectomy.3 Reported complications of clip migration include a nidus for stone formation,2 cholangitis,3 obstruction of the CBD,3 stenosis of the CBD, and most recently acute pancreatitis.

Clip migration has been reported from 11 days up to 6.5 years after laparoscopic cholecystectomy4 and up to 10 years after open cholecystectomy.1 The mechanism by which clips migrate into the CBD is not known. It has been hypothesized that clips may be applied incorrectly, resulting in incomplete closure of the cystic duct, causing a biloma, which later drains into the CBD via the cystic duct, permitting migration.3 It also has been suggested that clips cause local inflammation and necrosis of the CBD at its junction with the cystic duct, allowing migration through its wall. The use of absorbable clips theoretically would reduce the chance of clip migration; however, there already has been a report of such a clip migrating into the CBD.5

Management of clips within the CBD, including those acting as a nidus for stones, is usually removal after sphincterotomy at endoscopic retrograde cholangiopancreatography, although some clips pass spontaneously.

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References 

  1. Wu WC, Katon RM, McAfee JH. Endoscopic management of common bile duct stones resulting from metallic surgical clips (cat's eye calculi). Gastrointest Endosc. 1993;5:712–715
  2. Walker WE, Avant GR, Reynolds VH. Cholangitis with a silver lining. Arch Surg. 1979;114:214–215
  3. Raoul JL, Bretagne JF, Siproudhis L, et al. Cystic duct clip migration into the common bile duct: a complication of laparoscopic cholecystectomy treated by endoscopic biliary sphincterotomy. Gastrointest Endosc. 1992;38:608–611
  4. Ng WT, Kong CK, Lee WM. Migration of three endoclips following laparoscopic cholecystectomy. J R Coll Surg Edinb. 1999;44:200–202
  5. Onghena T, Vereecken L, Dwey K, et al. Common bile duct foreign body: an unusual case. Surg Laparosc Endosc. 1992;2:8–10

 Conflicts of interest The authors disclose no conflicts.

PII: S1542-3565(09)00996-3

doi:10.1016/j.cgh.2009.09.028

Clinical Gastroenterology and Hepatology
Volume 8, Issue 3 , Pages e24-e25, March 2010