Double chance findings during radiation-free ERCP/cholangioscopy in pregnancy: incipient cholecystectomy clip erosion and a perplexing intraheptic invagination-like stent artifact (with video)

A 34-year-old woman underwent ERCP because of complicated cholelithiasis with acute cholecystitis and bilirubin of 6.2 mg/dL. On cholangiogram, an impacted stone at the cystic duct (CD) takeoff emerged along with a higher, occlusive CD stone. The patient was referred for early cholecystectomy after placement of a 10F biliary double-pigtail stent. Repeated ERCP was scheduled 6 weeks later but was later postponed to 3 months because the patient became pregnant in the interim. At week 9, a completely radiation-free procedure was performed, including electrohydraulic lithotripsy of the obstructing stone (A). As is our institutional routine, full cholangioscopic exploration of the biliary system was performed. Of note, at the blind end of the CD a partially migrated surgical clip emerged (B). Even more intriguingly, in the right anterior system a wormlike, luminal structure emerged, tightly attached to a subsegment orifice with moderate inflammation (C, D). Targeted cholangioscopic biopsy specimens were taken with the novel SpyBite Max (Boston Scientific, Marlborough, Mass, USA) forceps, resulting in partial tearing off (Video 1, available online at www.giejournal.org). Histopathologic examination indicated exclusively necrotic cell material for the wormlike lesion and mixed inflammation for the ductal orifice. After reviewing the ERCP images, we considered this to most likely represent a novel and unique invagination-like artifact related to the longer-term indwelling double-pigtail stent.