Post-Cholecystectomy Clip Migration-Induced Acute Pancreatitis: A New Case and Review of the Literature

Abstract

Acute pancreatitis (AP) after laparoscopic cholecystectomy (LC) prompts a search for an inciting cause including stone/sludge, hypertriglyceridemia, drugs and genetic abnormalities. Our aim is to report a case and review the literature on post-cholecystectomy biliary clip migration as a cause of “unrecognized” AP. A 61 y/o man with a history of aortic stenosis, diabetes mellitus, & hyperlipidemia underwent uncomplicated LC for cholelithiasis with cholecystitis. He had 2 episodes of AP 15 & 19 months post-LC. He denied alcohol, smoking & family history of AP. His labs values at the time of diagnosis of AP are unknown. CT from first AP episode showed endoclips at the cystic duct stump and 1 endoclip within the distal end of the bile duct. After the first episode, he underwent ERCP without significant findings. At the time of his second episode of AP, an endoclip was noted in the duodenum. (Figure 1). Subsequent EUS revealed normal bile ducts & pancreatic parenchymal lobularity & honeycombing. He has been managed conservatively with no further AP episodes.1326_A.tif Figure 1: AP Secondary to Biliary Clip Migration1326_B.tif Figure 2: Image on left shows clip in bile duct (arrow) at first episode of AP. Image on right shows clip in duodenum (arrow) at second episode of AP.Proposed mechanisms for biliary clip migration induced AP include dehiscence at the cystic duct & clip slippage & migration or inadvertent clip placement into the bile duct with passage through the Ampulla of Vater. Clips within the biliary tree may also become a nidus for stone formation. This clip/stone combination can pass through the ampulla without incident or cause obstructive pathology such as recurrent AP or cholangitis. Review of the literature revealed 4 cases associating clip migration with AP (Table 1). Clip migration should be considered as a cause of AP in patients post-LC presenting with AP or recurrent AP with or without elevated liver enzymes. Diagnosis can be suggested by comparison of abdominal X-Rays to prior images to assess for changes in the number or location of clips. ERCP is a successful therapeutic option.