Sump Syndrome as a Complication of Choledochoduodenostomy

Abstract

Case Presentation and EvolutionA 71-year-old man initially underwent open cholecystec-tomy for biliary colic in 1990. Since then, he had been welluntil new symptoms began in 2009, when he presented to acommunity hospital reporting intermittent epigastric pain;ultrasound and computed tomography (CT) scans revealedcholedocholithiasis.Because an endoscopic retrograde cholangiopancrea-tography (ERCP) and stone extraction at that hospital wereunsuccessful, the patient underwent exploratory laparot-omy with common bile duct (CBD) exploration, duringwhich a CBD stone was removed and a side-to-side cho-ledochoduodenostomy (CDD) was performed.Several months following temporary postoperative reliefof his symptoms, the patient developed recurrent episodicright upper quadrant and epigastric pain, but withoutassociated jaundice or fever. He was referred to StanfordUniversity Medical Center, where he was seen by a gas-troenterologist for evaluation and further management.His past medical history included atrial fibrillation,hyperlipidemia, diabetes mellitus type II, and vestibularneuritis. Drug history included metoprolol, atorvastatin,metformin, dabigatran, dronedarone, and diltiazem. Thepatient had no known drug allergies. Socially, the patientdid not smoke and enjoyed only occasional alcohol. Therewas no family history of biliary tract disease.On examination, the patient appeared well and com-fortable, was slightly underweight, and had a soft and non-tender abdomen. The subcostal incision from his originalsurgery was visible but appeared well healed. Laboratoryfindings, including liver function tests, were normal (WBC7.9, Hb 13.4, Hct 39.4, Plts 257, Na 139, K 3.9, Cl 104,CO2 23, BUN 12, Cr 0.9, PT 15.4, INR 1.3, PTT 48.5, TBili 0.7, ALT 39, AST 16, Alk P 143, Glu 113, Ca 9.2). Anechocardiogram revealed mild mitral, aortic, and tricuspidvalve regurgitation, with an ejection fraction of 54%.Magnetic resonance cholangiopancreatography (MRCP)revealed a grossly dilated and tortuous CBD, as well asdilated common hepatic and intrahepatic ducts (Fig. 1a). Afluid–debris level was also seen in the CBD (Fig. 1b).Endoscopy revealed a patent side-to-side CDD anasto-mosis that could be entered with the gastroscope (Fig. 2).Moderate amounts of vegetable debris were seen in theCBD, and were removed using a rat-toothed forceps(Fig. 3). Using a duodenoscope, the CBD was also cann-ulated through the ampullary orifice and contrast injectionshowed an 18-mm-wide CBD with contrast extravasationthrough the stoma. Filling defects revealed further debris inthe distal CBD, which were cleared using a balloon cath-eter through the CDD.Following ERCP, the patient was immediately relievedof his symptoms. However, within a few days, the symp-toms recurred, and, again, included epigastric pain withoutjaundice or fever. Multiple further ERCPs were necessary,each revealing similar findings of vegetable debris withinthe CBD. Despite clearing the CBD during each procedure,the debris re-accumulated and symptoms always recurred.