2688 Blame It on the Migrating Stent: A Case Report

Abstract

INTRODUCTION: Endoscopic implantation of plastic or metal stents is widely used to manage gastric and biliary disorders. However, complications from stent migration have also been well-documented. Biliary stents usually pass through the intestine without complications. In the case where invasive intervention is necessary, endoscopic retrieval is preferred to prevent surgical intervention. We report an acute abdominal pain case presumably from stent migration. CASE DESCRIPTION/METHODS: A 56 yo woman with past medical history of SMA chronic mesenteric ischemia status post revascularization and choledocholithiasis status post stent placement presented to the hospital for acute abdominal pain with nausea and vomiting. One month ago, she had a metal common bile duct stent placed for choledocholithiasis with biliary obstruction. Imaging showed showed the dislodged stent and mild mid-small bowel loop thickening with mid-small bowel stent. Initially, gastroenterology recommended watchful waiting and she was discharged home in stable condition. She returned to the hospital for persistent abdominal pain. Repeat imaging showed the dislodged common bile duct stent within the distal loop of small bowel, now appearing abnormally thickened and hyperemic but no evidence for bowel obstruction. After review with the surgery team, she was taken for combined mesenteric angiogram and exploratory laparotomy as the stent was inaccessible by endoscopy due to its location. On angiogram, all GI vasculature was patent, however a stricture was found adjacent to the stent. The strictured bowel was surgically resected and the stent was removed. The stricture was related to the ischemic changes that she previously suffered from prior revascularization. Abdominal pain improved and she was discharged home after tolerating a regular diet. DISCUSSION: This case illustrates that when abdominal pain is out of proportion to the physical exam, a broader differential would provide a different perspective. Initially, the diagnosis was homed in on the stent migration as the etiology of acute abdominal pain. Unfortunately, histories of previous abdominal surgeries and SMA revascularization were not explored until later. The stricture was only discovered after exploratory laparotomy. This case demonstrates premature diagnosis can be detrimental to patient care. It is imperative to understand the entirety of the patient’s history in order to make not only the correct diagnosis but to intervene in a timely manner to prevent morbidity and mortality.