Single Intact Pill Causing Biliary Stent Obstruction.

CASE REPORT

A 68-year-old woman underwent cholecystectomy for a necrotic gallbladder, which was complicated by a bile leak for which a percutaneous drain was placed. Subsequent endoscopic retrograde cholangiopancreatography (ERCP) was performed for treatment of the bile leak with plastic stent placement. However, given continued bilious output from the percutaneous drain, repeat ERCP was performed to exchange the plastic biliary stent for a larger-caliber, fully-covered self-expanding metal stent, and her bilious output immediately improved to less than 10 cc/d.

One day before presentation, the patient's bilious drainage suddenly increased to 200 cc/d, her alkaline phosphatase increased from 109 to 336 U/L, and her total bilirubin increased from 0.8 to 3.4 mg/dL. Abdominal computed tomography showed a single radiopaque object within the common bile duct stent (Figure 1). Repeat ERCP was performed, and cholangiogram confirmed a single point of obstruction inside the stent and proximal common bile duct dilation (Figure 2).

Figure 1.

Abdominal computed tomography revealing a single hypoattenuating object within the common bile duct (arrow).

Figure 2.

Cholangiogram demonstrating the point of obstruction inside the stent (arrow) and proximal common bile duct dilation.

ERCP initially revealed a well-positioned metal biliary stent without bile flow. The biliary stent was assessed using an extraction balloon over a guidewire. Cholangiogram showed a single 10-mm round filling defect within the biliary stent. The biliary tree was swept with the extraction balloon, and a single orange pill was removed (Figure 3). Final cholangiogram demonstrated a patent biliary stent, and bile readily drained. On image inspection, the pill appeared to be an intact hydralazine 25 mg tablet, part of the patient's medication regimen (Figure 3). The patient continued all of her medications but was recommended to crush or cut medications when possible to reduce her risk of recurrent stent obstruction.

Figure 3.

Endoscopic images showing (A) an orange pill (arrow) within the stent, and (B) the orange pill (arrow) swept into the duodenal lumen.

Metal biliary stents have become the primary therapy to relieve biliary occlusion in patients with malignant biliary obstruction or benign biliary tract disease such as biliary strictures and leaks.[1] Occlusion of metal biliary stents is not uncommon and is usually caused by small debris or food. A study of 186 patients with metal biliary stents for malignant biliary strictures found a 36%–49% rate of occlusion.[2] In this study, the most common cause of obstruction was due to reflux of food residue or small debris, followed by stent dislocation or migration and hyperplasia around the stent.[2] Reports of uncommon foreign bodies causing obstruction within metal biliary stents are largely absent from the literature. Our case highlights a rare cause of biliary obstruction in a patient with a metal biliary stent, with repeat ERCP finding a single intact pill. The irony of this case is that instead of medication providing pharmacologic treatment, it led to an acute decompensation and urgent endoscopic intervention.

DISCLOSURES

Author contributions: A. Yeoh wrote the manuscript and is the article guarantor. M. Ryou edited the manuscript.

Financial disclosure: None to report.

Informed consent was obtained for this case report.