Endoscopic closure with an over-the-scope clip of a duodenocolonic fistula caused by a migrated biliary stent

Abstract

A 71-year-old man with diabetes, dementia, and gout presented with orange urine, nausea, and vomiting. The examination disclosed scleral icterus and jaundice. His laboratory determinations were suggestive of cholangitis: white blood count 21,500/μL, total bilirubin 21.5 mg/dL. CT of the abdomen showed the common bile duct (CBD) to be dilated up to 1.6 cm and migration of the biliary stent with the proximal end in the distal CBD, traversing through the duodenum and the distal end lying within the cecum (A). The duration of, or indication for, previous biliary stenting was not available. Endoscopy showed a straight plastic stent protruding from a bulging ampulla and penetrating the duodenal wall (B). The stent was removed with an alligator forceps, followed by ERCP with drainage of biliary sludge and pus and placement of a biliary stent. Contrast medium was injected with a sphincterotome through the duodenal opening of the fistula, which showed the fistula tract and filling of the cecum and subsequently the ascending colon without any peritoneal extravasation of contrast medium (C). The over-the scope clip (OTSC) anchor was used to retract the duodenal fistula opening, and a 12/6 gastrocutaneous OTSC was deployed for closure (D). An upper GI series was obtained the next day and showed that the OTSC was in a good position without any leak of contrast medium. The patient’s diet was advanced, and he was discharged home.