The Clip That Got Away: A Migrated Cholecystectomy Clip as a Nidus for Distal Common Bile Duct Obstruction and Stone Formation

Abstract

Purpose: 43 year old male presented with a one week history of fatty food intolerance, clay colored stools, and right upper quadrant pain. He underwent cholecystectomy 2 years ago for cholelithiasis and similar pain. A right upper quadrant ultrasound showed no ductal dilation, no intraductal lesion, and confirmed a previous cholecystectomy. Within 6 hours of admission, his bilirubin and alkaline phosphatase were double the normal values and his transaminases were seven times the normal values. A CT scan of the abdomen and pelvis with IV contrast showed no abnormalities from the AP view. Based on his clinical picture, ERCP was performed. The initial endoscopic image showed a clip encased in a stone at the ampulla (A). After wire cannulation past the stone, bile and pus began to flow out of the ampulla. A sphincterotomy was performed and the stone and clip were removed by balloon sweeps (B). Upon further review of the CT, a metal object was seen at the ampulla on sagital images (C)(box). Within 24 hours, the patient was back to his baseline and was discharged home. One similar case of a cholecystectomy clip causing obstruction and cholangitis was published in OVID (1).FigureFigureFigure