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Cholangitis many years after choledochoduodenostomy

Published:November 01, 2016DOI:https://doi.org/10.1016/j.gie.2016.10.031
      An 83-year-old man with a history of diabetes mellitus and coronary artery disease underwent surgical bile duct diversion (choledochoduodenostomy) in 1993 because of “gallbladder and bile duct problems.” His old records were unavailable. The patient presented to our emergency department with typical symptoms of cholangitis. During ERCP, a 4-mm to 5-mm opening on the anterior part of the duodenal bulb was visualized and identified as the choledochoduodenostomy. After cannulation of this choledochoduodenostomy, several large filling defects were seen inside the common bile duct (CBD) extending down toward the papilla (Video 1 and Fig. 1). The ampulla of Vater was cannulated, and a large sphincterotomy was performed. Next, massive amounts of intrahepatic and extrahepatic sludge, debris, and stones were removed (Video 1). A 10F, 15-cm plastic stent was then inserted to guarantee bile flow. During follow-up, the patient remained asymptomatic. After 2 months, the stent was removed, and patency of both the choledochoduodenostomy and the sphincterotomy site could be confirmed. “Sump syndrome” is a rare adverse event of a side-to-side choledochoduodenostomy, which may present many years later as acute ascending cholangitis. The “sump” refers to the distal CBD reservoir, where food debris, stones, sludge, or a combination of these substances accumulates. The main therapy for this syndrome is a biliary sphincterotomy. Lack of knowledge of this condition may lead to incomplete or failed ERCP and persistent cholangitis or choledocholithaisis.
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      Figure 1A, Opening in the anterior part of the duodenal bulb (choledochoduodenostomy). B, Giant stone within the common bile duct under fluoroscopic view.
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