International Journal of Clinical & Medical Images

A 64-year-old woman came to our observation for pain in the right upper abdominal quadrant and mild fever (38° Celsius) since three weeks. Her previous medical history included diabetes mellitus and a six years earlier hospitalization for acute lithiasic gangrenous cholecystitis and suppurative cholangitis: the patient underwent Endoscopic Retrograde holangiopancreatography (ERCP) with sphincterotomy and 10 Fr plastic stent positioning in the main biliary duct and open cholecystectomy. For the present clinical condition, the patient was investigated with abdominal X-ray showing the presence of a biliary stent (Figure A), while an abdominal ultrasound showed a 7 cm diameter hypo-anechogenic lesion in the right liver (Figure B). Blood exams revealed slight elevation of white blood cells (11.800/μL), C-reactive protein (12.59 mg/dL), and gammaglutamyltransferase (82 U/L). On physical examination the abdomen was tender and no masses were palpable. The workup comprised an esophagogastroduodenoscopy that found the forgotten biliary stent coming out from the duodenal papilla that was removed without complications. An abdominal Computed Tomography (CT) showed three abscesses (the largest measuring 52 x 51 x 47 mm) in the fifth and sixth hepatic segments and a complete portal thrombosis and cavernoma (Figure C). The patient was then hospitalised and submitted to intravenous antibiotic therapy with Piperacilline-Tazobactam and to transcutaneous ultrasound-guided drainage of the main hepatic abscess (the pus culture did not reveal the presence of bacteria or fungi and the cytological analysis was negative for malignant cells). The presence of cirrhosis, hepatobiliary malignancies, myeloproliferative and prothrombotic disorders as possible etiological factors for portal thrombosis were ruled out [1]. The patient started therapy with Warfarin and a CT scan at three months follow-up showed an almost complete resolution of the hepatic abscesses but the persistence of portal cavernoma (Figure D).

Interventional internal drainage of the biliary tract through ERCP has become an established procedure for the treatment of common bile duct stones. ERCP carries a high potential for complications and the most described complications associated with biliary stenting are stent occlusion, dislocation and migration of the stent, biliary or bowel perforation, intestinal haemorrhage or haemobilia and infections such as cholangitis, cholecystitis and hepatic abscess [2,3]. This case highlights the possibility of developing long-term complications of a forgotten biliary stent, such as multiple hepatic abscesses and portal thrombosis and
cavernoma, as a possible result of the chronic inflammation due to the presence of the biliary stent. In order to avoid long-term stent-related complications, a patients’ register should be set up and the stent removal should be planned since the first ERCP procedure.