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Enterolith Around a Migrated Biliary Stent

Second University of Naples 80138 Naples, Italy
A. Cardarelli Hospital 80131 Naples, Italy

A 72-year-old man presented to our emergency department with symptoms of intestinal obstruction. His medical history included sclerosing cholangitis, and his surgical history included subtotal gastrectomy with a Billroth II gastrojejeunostomy 3 years earlier and endoscopic biliary stent placement 1 year earlier to treat a biliary obstruction related to sclerosing cholangitis. Enhanced abdominal CT was performed. The scout view showed markedly dilated intestinal loops and an ovoid calcification in the right side of the abdomen. CT scans showed a 7-cm ovoid calcification adjacent to the biliary stent (Fig. 5). The stent was presumed to have migrated through the intestinal lumen into the afferent loop, causing a mechanical small-bowel obstruction. The patient underwent an enterotomy. No evidence of bowel perforation was found during the surgery, and the pathologic examination of the stone confirmed the presence of calcium bilirubinate, mucoprotein, and bacteria.

View larger version (105K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5. —72-year-old man with symptoms of intestinal obstruction. CT scan shows 7-cm ovoid calcification impinging on biliary stent in dilated small-bowel loop. Evidence of mesenteric edema is manifested as diffuse increase of mesenteric fat density.

Biliary stent migration is rare, but it has been reported recently as a cause of small-bowel or colonic perforation [1] occurring immediately after placement of the stent. However, cases of delayed presentation of intestinal perforation have been reported [2,3]. In addition, a case of small-bowel obstruction caused by the migration of a double-pigtail endoprosthesis has been recently reported [4].

Because we found no evidence of intestinal perforation or biliary dilatation in our patient, it is unlikely that the stone was formed in the biliary tree. Presumably, the biliary stent had migrated into the afferent loop, causing an enterolith to form. To our knowledge, no previous report has described a patient with a small-bowel obstruction caused by a migrated biliary periprosthesis that did not perforate the intestine. Our patient is the first case to be detected and documented using CT.

References

1. Storkson RH, Edwin B, Reierstesen O, Faerden AE, Sortland O, Rosseland AR. Gut perforation caused by biliary endoprosthesis. Endoscopy 2000;32:87 -89[Medline]
2. Esterl RM Jr, St. Laurent M, Bay MK, Speeg KV, Halff GA. Endoscopic biliary stent migration with small-bowel perforation in a liver transplant recipient. J Clin Gastroenterol 1997;24:106 -110[Medline]
3. D'Costa H, Toy E, Dennis MJ, Brown, C. Case report: intestinal perforation—an unusual complication of endoscopic biliary stenting. Br J Radiol 1994;67:1270 -1271[Abstract/Free Full Text]
4. Gerolami R, Codoul JF, Heyries L, Zamora C, Sahel J. Small bowel perforation and occlusion after migration of biliary and cystogastric prosthesis. Gastroenterol Clin Biol 2000;24:576 -578[Medline]

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