Duodenal Perforation After Biliary Stent Placement: How Early Should We Expect It? A Case Report

INTRODUCTION: Endoscopic placement of biliary stents is commonly performed to reestablish bile flow. Stent migration with intestinal perforation is a rare life-threatening complication. We report a case of a biliary stent causing an early duodenal perforation that was diagnosed laparoscopically four days after stent placement. CASE DESCRIPTION/METHODS: A 23-year-old woman presented with two days of worsening RUQ abdominal pain with associated dark urine and pale stool. On physical examination, she appeared ill and uncomfortable with scleral icterus and mild epigastric tenderness. Laboratory evaluation demonstrated a total bilirubin of 4.5 mg/dL, direct bilirubin of 2.8 mg/dL, ALT 354 mg/dL, AST 174 mg/dL, ALP 118 mg/dL , CA 19-9 143U/ml and normal hepatitis serologies. MRCP showed beading of the intrahepatic biliary tree with high grade strictures of the right and left hepatic ducts, suggesting Primary Sclerosing Cholangitis; cholelithiasis, choledocholithiasis with mild dilatation of the CBD and the intrahepatic biliary ducts (Figure 1). ERCP with sphincterotomy and stone extraction as well as brushings from the strictured portions was performed. A 7Fr x 9cm and a 7Fr x 15cm straight plastic stents were placed in the right and left intrahepatic ducts respectively (Figure 2). The evening after the procedure, she developed vomiting and abdominal pain together with elevated lipase and leukocytosis; findings attributable to post-ERCP pancreatitis. The next morning, she developed RLQ pain. She was scheduled to undergo laparoscopic cholecystectomy, so an exploration of the right lower quadrant was also planned. Laparoscopy reveled the biliary stent eroding through the duodenum causing a perforation (Figure 3). There was also significant bilious fluid leakage into the right paracolic gutter associated with inflammation. She underwent repair of the duodenal perforation and had a right hemicolectomy with ileocolic anastomosis. She did well post-op. DISCUSSION: Stent migration is a common complication and measures, such as creation of internal flanges and pigtails, have been taken to mitigate this. Consideration of indication, condition, size and other risk factors is important when assessing what type of stent to use. With the increased use of biliary stents, it is important for physicians to be aware of the many different complications that may arise. Although there are some well-established common complications, an astute physician will consider atypical presentations as cause for concern and further evaluation.Figure 1.: show beading of the intrahepatic biliary tree with high grade strictures of the right and left hepatic ducts.Figure 2.: 7Fr x 9cm straight plastic stent in the right intrahepatic system and a 7Fr x 15cm straight plastic stent in the left intrahepatic system.Figure 3.: Stent eroding through the duodenum.