Secondary Multiple Choledocholithiasis in Obstructive Jaundice Patient Due to Choledochoduodenal-Fistula Stricture

Abstract

Introduction Choledochoduodenal fistula is a rare condition in which an abnormal connection between the biliary duct and duodenum. The causes of choledochoduodenal fistula are cholelithiasis, pancreatobiliary tumor, and less common by duodenal ulcer. Fistula is advantageous as an alternate way of biliary drainage when the main biliary duct is obstructed. Case Illustration A 43 years old female, admitted with acute severe cholangitis. Patient was undergone cholecystectomy 3 years ago. Ultrasound and MRCP revealed biliary stone with dilatation of intra and extra hepatic biliary ducts. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated a fistula between bile duct and duodenum with stricture at distal part of fistula toward the duodenum, multiple biliary stone in the bile duct, and total obstruction at ampulla of Vater. The stricture at distal fistula made secondary-choledocholithiasis then lead to severe cholangitis, whereas the distal part of bile duct toward the duodenum was totally obstructed. Cannulation at fistula was performed, followed by inserting a plastic stent for urgent temporary bile-drainage. Subsequently, patient improved clinically. The plastic stent was changed by fully-covered self-expanding metal stent (SEMS) 3 days afterward. Six weeks later on follow up, after SEMS removal cholangiogram was obtained showing no stones in the bile duct. The bile concurrent with biliary stones passed spontaneously through the fistula while SEMS was in placed. Therefore, the patient did not require surgery intervention to remove biliary stones. Conclusion This case demonstrated a secondary choledocholithiasis in obstructive jaundice patient with acute severe cholangitis due to the choledochoduodenal fistula stricture. Inserting self-expandable stent in the fistula allows both bile and even biliary stone to pass spontaneously. This stent insertion may serve as an alternative practice to avoid surgery procedures on biliary drainage and removing biliary stones, in choledochoduodenal fistula cases.2162_A Figure 1. Multiple choledocholithiasis2162_B Figure 2. Self-Expanding Metal Stent (SEMS) insertion2162_C Figure 3. Post SEMS removal