P1491 - An Unusual Case of a Post-Cholecystectomy Clip as a Nidus for Obstructive Jaundice

Anish Paudel, MD¹, Suravi Khanal, MD¹, Sandesh Parajuli, MD¹, Parth Desai, DO¹, Kevin Gordon, MD², Robert Cooper, DO^2
1Tower Health-Reading Hospital, Reading, PA; ²Digestive Disease Associates, Reading, PA

Introduction: Most cases of obstructive jaundice are caused by choledocholithiasis or malignant strictures. Migration of the surgical clips into the common bowel duct is possible but is rarely described in the literature. The complications could include right upper quadrant pain, jaundice or cholangitis.

Case Description/Methods: A 70-year-old woman status post laparoscopic cholecystectomy 31 years prior presented with nausea for one week. Labs revealed alkaline phosphatase of 109 IU/L (ref: 34-104 IU/L), alanine transaminase 278 IU/L (ref: 7-52 IU/L), aspartate aminotransferase 21 IU/L (ref: 13-39 IU/L), total bilirubin 6.7 mg/dL (ref: 0.3-1.0 mg/dL) with direct bilirubin of 4.1 mg/dL (ref: 0.0-0.2 mg/dL). CT abdomen/pelvis with IV contrast showed intra and extrahepatic biliary ductal dilatation with linear hyper density within the distal common bile duct (Figure 1A, red arrow). Also noted were punctate dystrophic calcifications in the pancreatic head and a prominent pancreatic duct. Given the “double duct sign”, the patient underwent Endoscopic ultrasound that revealed multiple large choledocholiths with mild dilatation of the genu of pancreatic duct with no stricture. She underwent endoscopic retrograde cholangiopancreatography which revealed large common bile duct stones, one with an embedded surgical clip (Figure 1B, blue arrow). Biliary sphincterotomy and balloon sweep were performed with extraction of a trapezoid stone with embedded surgical clip within (Figure 1C). Plastic biliary stent was deployed given copious remaining debris within the bile duct. The patient’s total bilirubin returned to baseline normal over the next 2 days and she was discharged in stable condition.

Discussion: Post-cholecystectomy clip migration although can occur at any time after cholecystectomy but median time duration has been reported as 2 years. Most cases are successfully treated by ERCP however some may need surgical intervention. Although unusual, post cholecystectomy clip migration should be considered for in the differential for patients presenting with biliary symptoms in the setting of previous cholecystectomy as it may serve as a nidus for stone formation or cholangitis.


Disclosures:


Anish Paudel, MD¹, Suravi Khanal, MD¹, Sandesh Parajuli, MD¹, Parth Desai, DO¹, Kevin Gordon, MD², Robert Cooper, DO². P1491 - An Unusual Case of a Post-Cholecystectomy Clip as a Nidus for Obstructive Jaundice, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.