Chologenic diarrhea as the leading symptom of misplacement of a biliary stent into the colon

Introduction: Biliocolonic fistulas are usually associated with severe clinical symptoms including recurrent cholangitis, malabsorption and steatorrhea. We report a case in which misplacement of a biliary stent was associated with a mild clinical course, chologenic diarrhea being the leading symptom.

Case report: A 76-year old man was admitted to another hospital with an acute abdomen in October 2009. A perforating cholecystitis with gallstone ileus was diagnosed and cholecystectomy and a Billroth II resection of the stomach were performed. The postoperative course was complicated by sepsis and as a consequence of the inflammatory process in the upper part of the abdomen a fibrotic stenosis of the common bile duct (CBD) with dilation of intrahepatic bile ducts and jaundice developed. A percutaneous transhepatic biliary drainage was performed and the patient was transferred to our hospital for further management of cholestasis. ERCP with stent placement was attempted but unsuccessful, as it was not possible to introduce a guide wire into the papilla. Therefore a self-expanding nitinol stent was implanted into the CBD via a percutaneous transhepatic approach on February 5th, 2010. A cholangiography immediately after the procedure was interpreted as showing free drainage of the contrast material into the duodenum. The patient was discharged from hospital. During the following six months he suffered from chronic watery diarrhea, lost 10kg of weight, but had no other symptoms.

On August 16th, 2010 he was admitted to our hospital for evaluation of chronic diarrhea. A CT-scan demonstrated aerobilia and the nitinol stent draining from the CBD into the hepatic flexure of the colon. Colonoscopy showed the distal 0.5mm of the stent extending into the colon, and was otherwise normal. Retrospective evaluation of the radiologic images revealed that the misplacement of the stent into the colon had been visible immediately after the insertion of the stent. The nitinol stent was removed surgically and a choledochoduodenostomy was performed. During follow-up of six months the patient was asymptomatic and the watery diarrhea had stopped completely after the operation.

Discussion: This case demonstrates that biliocolonic fistulas do not always cause severe clinical symptoms like cholangitis, malabsorption or steatorrhea. Interestingly, in our patient over a period of six months watery diarrhea was the leading symptom of misplacement of a biliary stent into the colon. After exclusion of other etiologies this watery diarrhea had to be interpreted as chologenic diarrhea, which showed prompt resolution after surgical restoration of biliary drainage into the duodenum.