CASE 1644 Published on 20.05.2002
0

Duodenal perforation caused by a plastic biliary endoprosthesis

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

S. Sala, F. Loiacono, A. Giombi, M. Tilli, R. Galeotti

Connected authors
Patient

71 years, male

Categories
No Area of Interest ; Imaging Technique CT
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Clinical History
Abdominal pain and fever following placement of a biliary stent.
Imaging Findings
The patient was admitted with increasing jaundice (total bilirubin level 6.4mg/dl). Abdominal ultrasound showed dilatation of the intrahepatic biliary system caused by infiltrating gallbladder carcinoma. An endoscopic retrograde cholangiopancreatography (ERCP) confirmed the dilatation of the intrahepatic biliary ducts and showed a high-grade stenosis of the common hepatic duct. A 10-French 12cm plastic endoprosthesis was subsequently placed through the stenosis, with the proximal tip draining the intrahepatic biliary system and the distal tip properly protruding into the duodenum.

Twenty-four hours later, the patient complained of severe abdominal pain with clinical signs of peritoneal irritation and fever (39°C). A plain abdominal film did not show intraperitoneal free air. Abdominal spiral computed tomography (CT) with maximum intensity projection (MIP) and 3D volume rendering reconstructions revealed perforation of the transverse duodenum by the plastic prosthesis, which had migrated caudally through a hole in the duodenal wall into the retroperitoneal space. A large retroperitoneal fluid collection with air bubbles was also observed. Despite prompt percutaneous drainage of the collected fluid and endoscopically-guided replacement of the stent, the patient worsened and died 2 days later.

Discussion
Biliary stenting is a well-estabilished method for palliative treatment of bile duct strictures. On account of its increasing use, numerous complications are being reported, including cholangitis, cholecystitis, stent occlusion, rupture or migration. Duodenal perforation is a complication rarely reported after plastic stent implantation, while is more common with metallic stents. The stent can migrate downwards, impacting and puncturing the wall, especially in a duodenal diverticulum where the wall is thinner. Excessive protrusion of the endoprosthesis into the lumen of the duodenum may be a cause of duodenal wall perforation. Although uncommon, duodenal perforation secondary to biliary stent dislocation should be considered in all patients presenting with fever and abdominal pain after biliary stent insertion.
Differential Diagnosis List
Duodenal perforation by a plastic biliary endoprosthesis
Final Diagnosis
Duodenal perforation by a plastic biliary endoprosthesis
Case information
URL: https://www.eurorad.org/case/1644
DOI: 10.1594/EURORAD/CASE.1644
ISSN: 1563-4086
Figure 1

Spiral CT examination with reconstructions of volumetric data-set

Spiral CT examination with reconstructions of volumetric data-set
CT shows the biliary stent perforating the lateral wall of the duodenum and entering the anterior pararenal retroperitoneal space where air-fluid collection may be observed.
Spiral CT examination with reconstructions of volumetric data-set
Multiplanar MIP reconstruction shows the complete course of the biliary stent, perforating the duodenal wall. Various duodenal tracts may be easily observed.
Spiral CT examination with reconstructions of volumetric data-set
3D volume rendering reconstruction shows a panoramic view of the abdominal organs and main aortic visceral vessels, confirming duodenal wall perforation by the biliary stent.