We report a case of a 53-year-old man who presented with a history of recurrent fever
with intermittent jaundice over a few months. Ascending cholangitis was suspected.
Abdominal ultrasound showed no gallstone and an only slightly dilated common bile
duct (CBD). The patient’s blood tests were normal.
The patient was referred for endoscopic ultrasound (EUS). In the endoscopic suite,
the patient underwent deep sedation with full anesthetic monitoring. EUS was performed
using a curvilinear echoendoscope (GF UC 140P; Olympus, Tokyo, Japan). The EUS findings
showed an isoechoic oval shaped mass of 1.1 × 0.7 cm at the distal CBD, without CBD
dilation ([Fig. 1]). The patient then underwent endoscopic retrograde cholangiopancreatography (ERCP)
using the duodenoscope(Olympus TJF-160, Olympus America, Center Valley, Pennsylvania,
USA). The ampulla seemed normal on duodenoscopy ([Fig. 2]). A cholangiogram revealed a 12-mm CBD with an irregular shaped filling defect,
size 11 × 20 mm, at the distal CBD ([Fig. 3]). After endoscopic sphincterotomy, a polypoid mass of 1.5 × 1.0 cm popped out ([Fig. 4]). The stalk of this polyp was inside the CBD.
Fig. 1 Endoscopic ultrasound (EUS) showing an oval and non-shadowing mass at the distal
common bile duct.
Fig. 2 Endoscopic view of the major ampulla.
Fig. 3 Cholangiogram revealing an irregular filling defect at the distal common bile duct.
Fig. 4 Endoscopic view showing prolapsed common bile duct adenoma.
We decided to take a biopsy from the polyp, and planned for polypectomy later, so
a 10-Fr plastic stent (Cotton-Leung biliary endoprosthesis, Wilson-Cook Medical Inc.,
Winston-Salem, North Carolina, USA) was inserted for biliary drainage ([Fig. 5]). Pathological analysis showed a tubular adenoma with low grade dysplasia. The patient
was scheduled for polypectomy 2 weeks later. During the second procedure, the polyp
had disappeared, thus endoscopic retrograde cholangiography was performed. The cholangiogram
showed no residual filling defect at the distal CBD. Overtube-assisted cholangioscopy
using an ultraslim gastroscope showed only a residual small ulcer of about 4 mm diameter
at the distal CBD ([Fig. 6]). Our hypothesis for this unexpected event was that the pressure from the plastic
stent resulted in stalk necrosis. To our knowledge [1]
[2]
[3], such a case has not been previously reported.
Fig. 5 A 10-Fr plastic stent, 7 cm long, inserted into the common bile duct.
Fig. 6 Cholangioscopic view showing only a small ulcer at the distal common bile duct.
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