A 78-year-old man with neoplastic obstructive jaundice, who had undergone placement
of a percutaneous drainage catheter (10-Fr internal/external catheter), was admitted
for endoscopic retrograde cholangiopancreatography (ERCP). The cholangiogram revealed
an irregular stricture of the distal common bile duct. A hydrophilic guide wire was
inserted across the transhepatic drainage and recovered endoscopically; we removed
the percutaneous drain, performed a biliary sphincterotomy, and inserted an 8-cm Zilver
metallic stent (Wilson-Cook Medical Inc., Winston-Salem, North Carolina, USA). Three
days after ERCP, the patient underwent esophagogastroduodenoscopy with duodenal biopsies
taken for histological analysis; the latter identified an adenocarcinoma. Immediately
after esophagogastroduodenoscopy the patient developed acute abdominal pain. A CT
scan ([Fig. 1]) revealed free air in the abdomen and ascites around the spleen, in the right laterocolic
space, and among the jejunal loops. The patient underwent urgent laparotomy but no
bowel or biliary perforation was revealed. Intraoperative cholangiography showed correct
working of the biliary stent, but free passage of contrast medium was observed through
a fistula where the percutaneous drain had previously been. A cholecystectomy was
performed and a T tube left in place. The postoperative course was normal. It would
appear that air inflation during the esophagogastroduodenoscopy had facilitated the
passage of air from the duodenum to the peritoneum across the fistula created by the
percutaneous drain; the ascitic liquid, leaving a distance between the hepatic surface
and the abdominal wall, made development of the pneumoperitoneum even easier, because
of the incomplete consolidation of the biliocutaneous fistula.
Fig. 1 In a patient with a biliocutaneous fistula after percutaneous drainage, CT scan shows
free air in the abdomen and ascites around the spleen and liver, in the right laterocolic
space, and among the jejunal loops. The biliary stent is also visible.
In patients with a biliocutaneous fistula after percutaneous drainage, early endoscopic
examination with insufflation of air can facilitate free passage of air into the abdomen
from the fistula. Ascites may facilitate this process further; if ascites is present,
therefore, it may be useful to leave in place an external biliary drain after placement
of the stent to allow the fistula to consolidate. Definitive removal of the external
drain may be more safely carried out 3 – 5 days after the endoscopic procedure.
Endoscopy_UCTN_Code_CPL_1AK_2AD
Endoscopy_UCTN_Code_CPL_1AK_2AH
