1102
RIGHT STENT, WRONG HOLE: FROM PANCREATITIS TO APPENDICITIS
Date
May 21, 2024
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Treatment for various biliary and pancreatic disorders often involves endoprosthesis stent placement. The overall rate of migration for biliary stents is between 4.9-5.9%. Generally, these displaced stents pass without need for intervention.1 However, we present a case of appendicitis secondary to a lodged biliary stent that was successfully managed by endoscopic stent removal.
Patient is a 25 year-old male who presented with non-localizing abdominal pain. Three months prior to presentation, the patient had an episode of necrotizing pancreatitis secondary to choledocholithiasis. At that time, he underwent ERCP with sphincterotomy, balloon dilation, and stone extraction. A 10 Fr x 10 cm biliary stent was placed into the common bile duct (CBD). Two months after, interval CT imaging showed migration of the biliary stent into the cecum and development of a 7x3cm peripancreatic pseudocyst. Patient underwent EUS showing a 2x2cm multi-cystic lesion without septa in the pancreatic body. Repeat ERCP was performed with mild stenosis of the CBD, measuring 8mm, and a second plastic 10 Fr biliary stent was placed in CBD. Six days after repeat stenting, the patient presented to the emergency department (ED) with his chief complaint of abdominal pain. Repeat CT Abdomen/Pelvis showed persistence of the biliary stent in the cecum with extension into the appendix with mild stranding. Patient was discharged from the ED but re-presented two days later for persistent abdominal pain. Repeat CT abdomen/pelvis revealed fluid filled appendix with periappendiceal edema, concerning for acute appendicitis (Figure 1). Laboratory studies demonstrated mild leukocytosis (WBC 11.2). Patient was started on ciprofloxacin and metronidazole and underwent colonoscopy for stent retrieval. The stent was visualized in the cecum, with one end of the stent lodged in the appendiceal orifice and was successfully removed with a snare (Figure 2). The patient’s symptoms improved after removal and was discharged with five days of antibiotics. Patient presented to clinic two months later without symptom recurrence and was scheduled for laparoscopic cholecystectomy.
Biliary stent migration often occurs in the setting of dilated CBD, wide sphincterotomy, and balloon dilation.2 While infrequent, migrated biliary stents may require endoscopic removal. The most common site for migrated stent complications is in the duodenum, whereas complications in the small intestine and colon are rare.3 This patient developed appendicitis secondary to a displaced biliary stent. Stenting in the setting of appendicitis, known as endoscopic retrograde appendicitis therapy (ERAT), has been proposed as a therapeutic option.4 However, in this patient, the biliary stent caused the patient’s appendicitis. With endoscopic stent removal, the patient was able to avoid a surgical appendectomy.
Patient is a 25 year-old male who presented with non-localizing abdominal pain. Three months prior to presentation, the patient had an episode of necrotizing pancreatitis secondary to choledocholithiasis. At that time, he underwent ERCP with sphincterotomy, balloon dilation, and stone extraction. A 10 Fr x 10 cm biliary stent was placed into the common bile duct (CBD). Two months after, interval CT imaging showed migration of the biliary stent into the cecum and development of a 7x3cm peripancreatic pseudocyst. Patient underwent EUS showing a 2x2cm multi-cystic lesion without septa in the pancreatic body. Repeat ERCP was performed with mild stenosis of the CBD, measuring 8mm, and a second plastic 10 Fr biliary stent was placed in CBD. Six days after repeat stenting, the patient presented to the emergency department (ED) with his chief complaint of abdominal pain. Repeat CT Abdomen/Pelvis showed persistence of the biliary stent in the cecum with extension into the appendix with mild stranding. Patient was discharged from the ED but re-presented two days later for persistent abdominal pain. Repeat CT abdomen/pelvis revealed fluid filled appendix with periappendiceal edema, concerning for acute appendicitis (Figure 1). Laboratory studies demonstrated mild leukocytosis (WBC 11.2). Patient was started on ciprofloxacin and metronidazole and underwent colonoscopy for stent retrieval. The stent was visualized in the cecum, with one end of the stent lodged in the appendiceal orifice and was successfully removed with a snare (Figure 2). The patient’s symptoms improved after removal and was discharged with five days of antibiotics. Patient presented to clinic two months later without symptom recurrence and was scheduled for laparoscopic cholecystectomy.
Biliary stent migration often occurs in the setting of dilated CBD, wide sphincterotomy, and balloon dilation.2 While infrequent, migrated biliary stents may require endoscopic removal. The most common site for migrated stent complications is in the duodenum, whereas complications in the small intestine and colon are rare.3 This patient developed appendicitis secondary to a displaced biliary stent. Stenting in the setting of appendicitis, known as endoscopic retrograde appendicitis therapy (ERAT), has been proposed as a therapeutic option.4 However, in this patient, the biliary stent caused the patient’s appendicitis. With endoscopic stent removal, the patient was able to avoid a surgical appendectomy.
Figure 1. (a) Axial view of biliary stent in the appendix with fluid and soft tissue stranding (b) Sagittal view of the biliary stent (c) Coronal view of biliary stent
Figure 2. (a and b) Biliary stent entering appendiceal orifice (AO) (c) AO after biliary stent removed (d) 10 Fr biliary stent after removal
