Choledochoduodenal Fistula With Cholangitis and Duodenal Obstruction: A Rare Complication of Pancreatic Cancer Managed With Endoscopic Therapy

Abstract

SymbolIntroduction: Pancreatic cancer is the fourth leading cause of cancer deaths in the United States. Formation of a spontaneous choledochodudodenal fistula (CDF) is rare with an estimated incidence of 3-5%. Self-expanding metal stents (SEMS) are commonly used to treat obstructive jaundice in patients with unresectable pancreatic head cancers. Spontaneous CDF can be caused by tumor invasion, bile duct stones, cholangitis, stent migration or chemoradiation and are usually managed surgically. We present the case of a patient with an advanced pancreatic head adenocarcinoma and a spontaneous CDF with cholangitis and duodenal obstruction managed endoscopically. A 67-yearold woman with unresectable pancreatic adenocarcinoma metastatic to the liver presented with RUQ abdominal pain, fever, hyperbilirubinemia, rigors, nausea and an inability to tolerate oral intake. PMHx is significant for chemoradiation and biliary SEMS placement 7 months prior. Diagnosis of acute cholangitis was made, and IV fluids and antibiotics were started. Upper endoscopy noted a large cavity with surrounding ulcer in the medial wall of the duodenum through which the mid portion of the previously placed metal CBD stent was visible consistent with a CDF. Severe luminal narrowing in the posterior duodenal bulb restricted access to the ampulla and conventional ERCP. APC and balloon dilation of the SEMS through the CDF were performed to access the obstructed biliary system. This technique is similar to EUS-guided choledochoduodenostomy. A plastic biliary stent was placed to relieve the biliary obstruction and cholangitis resolved. Surgical consultation deemed patient was not a surgical candidate due to advanced disease and poor nutritional status. Patient returned for endoscopy 3 days later. CDF tract widened with APC and a new SEMS placed through the fistulous tract. Ultrathin endoscope used to traverse narrowed duodenum and facilitate palliative duodenal stent placement. Patient’s symptoms resolved, nutritional status improved, and she was able to start a new course of palliative chemotherapy 1 week later. She was feeling well at 60 days of follow-up. In summary, cases of choledochoduodenal fistula, previous metal biliary stent placement, duodenal obstruction and cholangitis are rare complications of pancreatic cancer and can present a difficult management challenge in patients who are not candidates for surgical therapy. Endoscopic drainage of the obstructed biliary system can be accomplished by using APC and balloon dilation and then stenting through the CDF and may be a viable alternative to surgery.Symbol