Document Type

Conference Proceeding

Publication Date


Publication Title

J Gen Intern Med


CASE: A 67-year-old female presented acutely with abdominal pain associated with nausea and vomiting. Her history is notable for newly diagnosed liver cirrhosis of unknown etiology and diverticulitis status post colectomy. Upon presentation, patient was alert and oriented. On examination, she was febrile with jaundice and generalized abdominal tenderness. Workup demonstrated leukocytosis of 14.3, hemoglobin at baseline of 8.7, AST 39, ALT 16, ALP 341, and total bilirubin 0.9. CT abdomen showed moderate ascites with distended gallbladder and wall thickening. Abdominal US and HIDA scan were consistent with acute cholecystitis. Given poor surgical candidacy, patient underwent ERCP that demonstrated choledocholithiasis and biliary papillary stenosis with patent cystic duct. Stent was placed in the common bile duct to maintain patency due to the presence of papillary edema. She had clinical and laboratory improvement afterwards. Patient subsequently developed a fever with persistent RUQ pain. She had worsening hyperbilirubinemia to 4.0 and recurrence of leukocytosis to 14.0. Hemoglobin was stable around 8.0. She was started on antibiotics for cholangitis. Repeat ERCP showed that the previously placed biliary stent was occluded with a clot secondary to a post-sphincterotomy bleed. This warranted stent removal and replacement with a fully covered metal stent. Cystogram following procedure revealed a patent cystic duct. She had clinical improvement with decrease in bilirubin to 2.2 after which she was discharged. IMPACT/DISCUSSION: ERCP is a diagnostic and therapeutic tool for the management of biliary and pancreatic diseases. It involves navigating an endoscope through the upper gastrointestinal tract and traversing the major duodenal papilla to access biliary and pancreatic ductal systems. This instrumentation is responsible for complications that include pancreatitis, cholangitis, hemorrhage, or perforation. This case offers a rare complication of ERCP involving biliary obstruction secondary to post-ERCP bleeding with subsequent cholangitis. Bleeding after this procedure is typically associated with a decrease in hemoglobin, hemodynamic instability, or overt signs of hemobilia which our patient did not demonstrate. Localized bleeding at the common bile duct resulted in a clot that completely occluded the recently placed stent, resulting in an iatrogenic biliary obstruction. Management of this complication involves repeat ERCP for stent retrieval, bleeding control, and biliary drainage after which laboratory and clinical parameters improve. CONCLUSION: Internists should be aware of the potential complications that occur in the immediate period after ERCP. Changes in a patient's exam or laboratory values including cholestatic markers and complete blood count should prompt re-evaluation with imaging or repeat ERCP when indicated. This case highlights the clinical presentation and management for iatrogenic biliary obstruction secondary to biliary stent clotting after ERCP.




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