Presentation
Abdominal pain and sepsis of unknown etiology. History of cholecystectomy and common bile duct (CBD) stent placement for pancreatic head adenocarcinoma (stage 2).
Patient Data
CT of the abdomen demonstrates a stent located within the common bile duct (CBD) and an elongated cystic structure located adjacent to the CBD proper. Surgical clips are seen at the distal end of this structure, from prior gallbladder removal. A small amount of non-dependent pneumobilia is present, as expected with the presence of a biliary stent. There is no intra- or extrahepatic biliary dilation; a small air-fluid level is seen within the CBD stent proximally.
MR abdomen with MRCP protocol demonstrates post cholecystectomy changes and a stent in place within the CBD. There is an elongated dilated structure adjacent to the CBD with surgical clips at the distal end and junctional connection with the CBD at the proximal end, determined to be a dilated cystic duct. No obvious evidence of intra- or extrahepatic biliary obstruction as indicated by the persistent T2 signal throughout the biliary stent.
Radiotracer is seen physiological taken up by the liver and subsequently excreted into the biliary tree and small bowel indicated patency. There is reflux of tracer adjacent to the CBD which was originally thought to represent the second portion of the duodenum, but was later deemed to be more likely within a dilated cystic duct as no tracer was seen within the region of the stomach even on delayed imaging.
ERCP demonstrated a single plastic stent in place with distal obstruction. The stent was removed and replaced with a covered metal stent with the proximal end positioned 3 cm below the biliary bifurcation and the distal end within the ampullary outlet. Bile was seen to flow through the stent, indicating patency.
Case Discussion
This patient presented with signs of sepsis and pseudomonas bacteremia who was found to have a dilated cystic structure on CT imaging which was later deemed to be a dilated cystic duct secondary to obstructed common bile duct stent. The cystic structure was originally worrisome for a post-surgical abscess or collection that was the source of the sepsis and bacteremia.
His liver function tests were not significantly elevated on admission and he did not meet criteria for cholangitis. The CBD stent was found to be occluded on endoscopic retrograde cholangiopancreatography (ERCP), despite the imaging demonstrating patency, including free flowing of tracer seen on the HIDA scan.
The patient's sepsis started to improve and he made a recovery after the biliary stent was replaced, leading to depressurization of the biliary tree and dilated cystic duct.
CO-AUTHOR: Parastou Einafshar, MD
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