Choledochoduodenal fistula after biliary placement of a self-expanding metallic stent for palliation of pancreatic cancer

Abstract

A 56-year-old man with pancreatic cancer underwent palliative placement of a biliary self-expanding metallic stent (SEMS) for obstructive jaundice after chemoradiation (nine cycles over 5 months). He presented with melena but denied abdominal pain, nausea/vomiting, or hematemesis. Hemoglobin concentration was 6.5 g/dL and serum bilirubin 1.0 mg/dL (normal: 13.8 – 17.2 g/dL and < 1.9 mg/dL, respectively). Abdominal CT with intravenous contrast showed pneumobilia and mucosal hyperenhancement in the gastroduodenal area. After blood transfusion, an upper endoscopy was performed which showed that the duodenal bulb was extrinsically compressed and eroding medially through the duodenal wall with the covered biliary SEMS ([Fig. 1]) surrounded by a large circumferential ulcer ([Fig. 2]). No active bleeding was seen and no therapeutic intervention was performed. The patient continued to have melenic stools. Subsequent colonoscopy was unremarkable. Mesenteric angiography was performed in attempt to prophylactically embolize the gastroduodenal artery, but was technically unsuccessful because of a narrowed gastroduodenal artery which was not actively bleeding. The patient died from exsanguination later that day.