Sarav Gunjit Singh Daid, MD1, Eddie Copelin, MD2, Amer Malik, MD1; 1Roger Williams Medical Center, Providence, RI; 2Winthrop University Hospital, Mineola, NY
Introduction: Acute Cholangitis from common bile duct obstruction is an indication for emergent ERCP. Surgical clip migration into the common bile duct as the etiology of acute cholangitis is a rare phenomenon in laparoscopic cholecystectomy that is not entirely understood. To our knowledge, surgical clip migration causing acute cholangitis is a documented but rare complication with few published cases to date.
Methods: A 54-year-old female with a history of asthma, gastroesophageal reflux disease, diverticulitis, pancreatitis, and laparoscopic cholecystectomy three years ago presented with a 2-day history of epigastric right upper quadrant pain. The patient had a fever of 101.3F; her liver function tests were abnormal, and an abdominal CAT scan showed a linear high-density object in the distal common bile duct most likely felt to be a surgical clip. Next, an MRCP showed the question of a migrated surgical clip to the distal common bile duct. Subsequent ERCP was inconclusive. However, follow up X-ray (KUB) afterward showed the clip in the RUQ suggesting that the clip may have passed further down the bowel duct and it was decided to do ERCP with spyglass for better visualization. The initial view during ERCP with the spyglass did not reveal the metal clip. The metal clip was then visualized on fluoroscopy after the withdrawal of the endoscope. A conventional biopsy forceps retrieved the metal clip from the bile duct. The patient tolerated the procedure well with no complications. Her LFTs trended down abdominal pain resolved. Pt was discharged the next day with a one week follow up that resulted in a benign physical exam and LFTs Discussion: Acute Cholangitis from a surgical clip is a rare complication of laparoscopic cholecystectomy. The exact mechanism behind the migration of the surgical clip is not well understood. However, the hypothesis that has been stated is that increased pressure applied to the clipped collecting duct by the liver promotes necrosis allowing the clips to then invagination and fall into the common bile duct, thus serving a nidus for gallstone formation. The range of presentations may be from 11 days to 20 years with a median of 26 months. The most common diagnosis at presentation is obstructive jaundice (37.7%) followed by cholangitis (27.5%) with biliary colic. Acute cholangitis secondary to clip migration after laparoscopic cholecystectomy should be recognized early with accurate imaging and treated with ERCP and stone extraction.
Retrograde catheterization of the common bile duct demonstrates an adjacent malpositioned, migrated surgical clip (arrow) and a wire extending into the hepatic duct above the clip.
Status Post Surgical Clip Removal
Disclosures: Sarav Gunjit Singh Daid indicated no relevant financial relationships. Eddie Copelin indicated no relevant financial relationships. Amer Malik indicated no relevant financial relationships.