Obstructive jaundice with a biliary clot post-endoscopic sphincterotomy treated with clipping and endoscopic biliary stenting

A 62-year-old man was admitted with epigastralgia. He had a history of laparoscopic cholecystectomy for cholecystolithiasis. He had no coagulopathy and was not taking anticoagulants. Abdominal computed tomography (CT) showed a common bile duct (CBD) stone ([Fig. 1 a]). Endoscopic retrograde cholangiography (ERC) and intraductal ultrasonography (IDUS) also showed a 2.8-mm CBD stone ([Fig. 1 b, ] [Fig. 2 a, b]). Endoscopic sphincterotomy (EST) was performed ([Fig. 2 c]) and the CBD stone was removed using a wire basket ([Fig. 2 d]).

Fig. 1 Common bile duct stone (arrow). a Abdominal computed tomography. b Endoscopic retrograde cholangiography.

Fig. 2 Removal of the common bile duct (CBD) stone. Endoscopic views (a, c, d) and intraductal ultrasonography (IDUS) view (b). a The ampulla of Vater was intact (arrow). b IDUS showed a CBD stone, approximately 2.8 mm in size (arrow). c Immediately after endoscopic sphincterotomy (arrow). d The CBD stone was removed using a wire basket (arrow).

The patient complained of epigastralgia again after 4 days. Laboratory investigations demonstrated elevated cholestatic parameters: total bilirubin 2.8 mg/dL (normal range 0.4 – 1.5 mg/dL), aspartate aminotransferase 176 U/L (13 – 30 U/L), alanine aminotransferase 146 U/L (10 – 42 U/L), alkaline phosphatase 233 U/L (38 – 113 U/L), and gamma-glutamyl transpeptidase 695 U/L (9 – 32 U/L); hemoglobin was within the normal limit. CT showed a diffuse high-density structure in the CBD, with the bile duct mildly dilated ([Fig. 3 a]). ERC revealed post-EST bleeding and a biliary clot in the CBD ([Fig. 3 b, ] [Fig. 4 a]). The clot was removed using a grasping forceps and wire basket ([Fig. 3 c], [Fig. 4 b]), and an endoscopic biliary stent (EBS) was inserted into the CBD for biliary drainage. Clipping was applied to stop the bleeding ([Fig. 3 d], [Fig. 4 c, d, ] [Video 1]). The patient progressed well after the procedures. The EBS was removed 8 days postoperatively and the patient was discharged 10 days postoperatively.

Fig. 3 Imaging after endoscopic sphincterotomy (EST) and common bile duct (CBD) stone removal. a Reconstructed coronal image of abdominal computed tomography on day 4 after EST showed a diffuse high-density structure in the CBD with the bile duct being mildly dilated (arrows). b Endoscopic retrograde cholangiography revealed a diffuse filling defect in the CBD with the bile duct mildly dilated (arrows). c The CBD was cleaned up by removing the biliary clot using a grasping forceps and wire basket. d An endoscopic biliary stent was inserted into the CBD and clipping was applied for endoscopic hemostasis.

Fig. 4 Treatment of the biliary clot and delayed bleeding after endoscopic sphincterotomy (EST). Endoscopic views. a Post-EST delayed bleeding and the clot at the orifice of the common bile duct (CBD). b The biliary clot was removed using a grasping forceps. c The bleeding point was revealed (arrow). d An endoscopic biliary stent was inserted into the CBD and clipping was applied to stop the bleeding.

Video 1 The biliary clot, caused by delayed bleeding after endoscopic sphincterotomy, was removed using a grasping forceps and wire basket, and clips were applied to stop the bleeding.

The incidence of post-EST delayed hemorrhage is 1.62 % [1], and biliary obstruction with a biliary clot caused by post-EST bleeding is extremely rare [2] [3] [4] [5]. Endoscopic hemostasis is currently the first treatment choice for post-ERC bleeding, with balloon dilation and biliary stent placement used for treatment [2] [3] [4] [5]. To the best of our knowledge, this is the first English case report of obstructive jaundice with a biliary clot caused by post-EST bleeding, treated with clipping and an EBS, which may be an effective endoscopic technique for treating such cases.

Endoscopy_UCTN_Code_CPL_1AK_2AC

Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Yan J, Zhou CX, Wang C. et al. Risk factors for delayed hemorrhage after endoscopic sphincterotomy. Hepatobiliary Pancreat Dis Int 2020; DOI: 10.1016/j.hbpd.2019.12.010.
• 2 Mosenkis BN, Brandt LJ. Bleeding causing biliary obstruction after endoscopic sphincterotomy. Am J Gastroenterol 1997; 92: 708-709
• 3 Ala A, Khin CC, van Someren N. Common bile duct thrombus: a cause of persisting obstructive jaundice after endoscopic sphincterotomy. Gastrointest Endosc 1999; 50: 285-286
• 4 Ergül B, Koçak E, Köklü S. An unusual complication of ERCP: obstructive jaundice due to a blood clot. Clin Res Hepatol Gastroenterol 2012; 36: e40-e41
• 5 Zhu Y, Wang S, Zhao S. et al. Obstructive jaundice due to a blood clot after ERCP: a case report and review of the literature. BMC Gastroenterol 2018; 18: 163

Publication History

Article published online:
08 October 2020