3040 An Uncommon Presentation of Post-Cholecystectomy Bile Leak in the Setting of Existing CBD Stent Successfully Managed With Metallic Stent Placement

Abstract

INTRODUCTION: About 1% of patients undergoing cholecystectomy develop bile leaks. Bile leaks from cystic duct stump or from a duct of Luschka are the most common sites. Endoscopic biliary sphincterotomy and stent placement remains cornerstone in management of most post-operative bile leaks. We present an unusual case of post cholecystectomy bile leak from cystic duct stump in the presence of existing common bile duct stent. CASE DESCRIPTION/METHODS: A 48-year-old lady presented with 4 days history of worsening abdominal pain after cholecystectomy. She was admitted one week ago for acute exacerbation of chronic pancreatitis and underwent repeat ERCP. A plastic biliary and pancreatic stent was placed. She complained of RUQ pain and underwent HIDA scan which showed delayed gall bladder emptying suspicious for chronic cholecystitis. Given history of recurrent acute pancreatitis and chronic cholecystitis, cholecystectomy was recommended. Patient underwent laparoscopic cholecystectomy one week before this presentation. Abdominal exam on admission showed severe diffuse abdominal tenderness. X ray abdomen in ER showed non obstructive bowel pattern and possible ileus but no perforation. Labs showed WBC 13,000, TB 1.0, AST 11, ALT 20, ALP 186 and lactate 1.0. Given significant abdominal tenderness a CT abdomen and pelvis was done which showed moderate to large subcapsular and intraperitoneal fluid and 2 cm caudal migration of CBD stent with slight prominence of the adjacent common bile duct. HIDA scan showed collection of radionuclide activity along the inferior margin of the liver, increasing overtime, consistent with bile leak. A CT guided percutaneous drain was placed. Patient underwent ERCP 2 days after presentation. Cystic duct stump bile leak was seen which was treated with placement of 8 mm × 60 mm self-expandable fully covered metallic biliary stent (FCSEMS). Distal common bile duct stricture was again seen, measured 2.5 cm in length. Patient underwent repeat ERCP one month later with showed healed site of cystic duct stump leak. DISCUSSION: Presence of CBD stent does not preclude diagnosis of post cholecystectomy bile leak. In our case, CBD stricture, multiple previous endoscopic interventions and stent migration were reasons for failure to eliminate the transpapillary pressure gradient, thereby permitting preferential extravasation at the site of the leak. Further research is needed to establish role of FCSEMS in management of complicated biliary leaks especially in setting of CBD stricture.