Suture material in the CBD causing recurrent stones

Omair Atiq, MD, and Deepak Agrawal, MD, from the Department of Internal Medicine, Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, in Dallas, Texas, USA, share this VideoGIE case, “Suture material in the common bile duct causing recurrent stones.”

We presented a case of an elderly female with recurrent episodes of abdominal pain and cholangitis due to common bile duct (CBD) stones. She had had multiple ERCPs for stones removal and stricture dilation. Multiple abdominal ultrasounds and CT scans failed to reveal a cause for recurrent stone formation. We decided to endoscopically evaluate the CBD lumen by cholangioscopy. A large prior sphincterotomy allowed us to perform direct cholangioscopy using an ultrathin upper endoscope. Suture material was seen embedded in CBD mucosa at the site of cystic duct take off. This was likely placed at the time of her cholecystectomy many years ago and was behaving as a nidus of stone formation. During this endoscopy, we were able to remove the suture material with the help of pediatric biopsy forceps.

Our video highlights 2 important aspects of this case – First, cholangioscopy should be considered in patients with recurrent bile duct stones as retained clips, sutures may be a nidus for recurrent stone formation. Second, direct cholangioscopy with an ultraslim endoscope is a feasible option in these cases and may be preferred (compared to mother-daughter system) due to better optics and have more options to use different endoscopic accessories. For example, in our case we used pediatric biopsy forceps, which allowed us to pull on the sutures with sufficient force.

Bile duct stones demonstrated 6 months or more after a cholecystectomy and ERCP with sphincterotomy are considered to be recurrent, with an estimated occurrence in 4%–24% of patients. Factors predisposing to recurrent choledocholithiasis include malignancy, benign stricture, bacterial infection, infestation and foreign bodies. Common foreign bodies include metallic hemoclips, suture materials, retained tubes and ingested foods. It is often difficult to evaluate the cause of recurrence without direct visualization of the bile duct as cholangiogram may not show mucosal abnormality. Therefore it is beneficial to endoscopically evaluate bile duct in cases of recurrent CBD stones and indeterminate strictures. Ultraslim endoscope has added advantage of better visualization, cleaning/suctioning capabilities and passage of instruments over mother-daughter duodenoscope.

Figure 1. Direct cholangioscopy. A, Ultraslim video endoscope in the common bile duct showing suture material embedded in mucosa adjacent to the stricture. Sludge and stones were also visible. B, Suture material removed with the help of pediatric biopsy forceps.

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The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

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