Post written by David M. de Jong, BSc, from the Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands.

A 62-year-old man was referred to our tertiary hospital for endoscopic therapy of previously diagnosed alcoholic chronic pancreatitis. After initial stent placement, he underwent electrohydraulic lithotripsy (EHL) of 2 pancreatic duct stones at a second procedure. Surprisingly, backflow of contrast into the bile duct was noted, strongly suggestive for a pancreatico-biliary fistula. Two months later, the patients was hospitalized for acute cholangitis. A CT scan showed compression of the bile duct by the pancreatic stone, and a biliary stent was placed during urgent ERCP. At the fourth ERCP, fluoroscopy revealed a calcified stone in the common bile duct (CBD). The procedure is shown in the video. Spyglass cholangioscopy was performed, and a large pancreatic stone was seen. The stone was successfully treated with EHL. We hypothesized that the stone migrated into the CBD via a fistula from the Santorini duct after the second ERCP.

Cholangitis due to pancreatico-biliary fistula has only been described in cases of intraductal papillary mucinous neoplasms or impacted pancreatic stones. Cholangitis due to a migrated pancreatic stone into the CBD, as was the case in our patient, is a very rare clinical presentation. In contrast to bile stones, which are usually cholesterol type stones and not radiopaque, pancreatic stones are usually visible on plain fluoroscopy images as focal calcifications and appear as white calculi on endoscopic imaging. The removal of pancreatic stones often requires lithotripsy.

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