De Novo Stent-Stone Complex Formation With Resultant Secondary Sclerosing Cholangitis: A Case Report and Literature Review

Abstract

Listen

Translate article

Introduction: Long-term biliary stenting, especially unintended and forgotten stents, could cause lifethreatening complications. We report a case of 23-year-old female who had unintended long-term biliary stenting that resulted in obstructive jaundice and secondary sclerosing cholangitis, which carries high morbidity and mortality. Case Report: A 23-year-old female underwent laparoscopic cholecystectomy with intraoperative cholangiogram showing choledocholithiasis. Postoperative endoscopic retrograde cholangiopancreatography (ERCP) with biliary stenting was done and patient was recommended to follow-up with gastroenterology in 1 week for repeat ERCP. Patient was lost the follow-up and after 5 years she presented with right upper quadrant pain and obstructive jaundice. First ERCP showed stentstone complex which could not be removed with conventional methods and mechanical lithotripsy. A new stent was placed and sphincterotomy was done. During second ERCP with SpyGlass® and electrohydraulic lithotripsy, multiple attempts were again unsuccessful. She had surgical common bile duct (CBD) exploration, stone-stent complex was removed and T-tube was placed. Liver biopsy done during surgery showed cholestasis and portal reactive inflammation and fibrosis, consistent with large bile duct obstruction. Discussion: Retained foreign objects including stents, fragments of T-tube, surgical clips, and suture material can act as a nidus for stone formation. Complications associated with long-term biliary stents include stent occlusion, recurrent cholangitis, biliary colic, stent migration, CBD ulceration, fistula formation, perforation, formation of stent-stone complexes, and chronic biliary obstruction resulting in secondary sclerosing cholangitis. For stent-stone complex 2 hypothesized mechanisms were proposed in a case series: type A and type B. Secondary sclerosing cholangitis (SSC) has features similar to primary sclerosing cholangitis (PSC), but with known pathologic processes causing chronic biliary obstruction, most commonly from surgical trauma followed by biliary stones. Other reported causes include biliary tumors, ischemia, chemicals such as floxuridine used in treatment of metastatic colon cancer, antibiotics, and cystic fibrosis. SSC patients have shorter life expectancy compared to PSC. It is recommended to closely monitor SSC patients with 3-6 months of liver function tests, Imaging studies for cholangiocarcinoam and hepatoma and also screening for esophageal varices. Our case emphasizes on judicious use of long-term biliary stents and close follow-up because of the risk of life-threatening complications. Permanent biliary stents should be restricted to patients unfit for elective procedure later on or with limited life expectancy.