An 84-year-old woman was admitted for cholangitis. Her leukocyte
count was 14.76 Gpt/L (normal range
4.0 – 10.0 Gpt/L), total bilirubin was
67 mmol (normal < 17 mmol), alkaline phosphatase was
6.48 mmol (normal range 0.58 – 1.74 mmol) and
γ-glutamyltransferase was 7.04 (normal range
0.1 – 0.7). The past medical history was remarkable for a
cholecystectomy and a choledochoduodenostomy carried out 21 and 15 years ago,
respectively. An abdominal ultrasound carried out after admission to the
referring hospital showed dilation of the common bile duct (CBD) and
choledocholithiasis. Therapy with tazobactam/piperacillin and metronidazole was
started. Endoscopic retrograde cholangiopancreatography (ERCP) was carried out
twice at the same hospital but failed both times, and the patient was referred
to our medical center.
We carried out another ERCP, which disclosed an opening in the
duodenal bulb ([Fig. 1]) and an intact ampulla of
Vater. Cholangiography revealed multiple filling defects in the distal CBD and
contrast extravasation into the stomach via the duodenal orifice
(choledochoduodenostomy) ([Fig. 2]). Deep
cannulation of the intrahepatic bile ducts was accomplished after passing a
guide wire ([Fig. 2]). The intrahepatic biliary
tree could only be visualized on occlusion cholangiography with the balloon
inflated above the choledochoduodenostomy ([Fig. 3]). A sphincterotomy was carried out with
subsequent extraction of multiple stones and a large amount of sludge ([Fig. 4]). The patient recovered and on follow-up 6
months later, she is doing well.
Fig. 1 The opening of the
choledochoduodenostomy located at the 7 o’clock position.
Fig. 2 Cholangiogram showing
multiple filling defects in the common bile duct and extravasation of contrast
material into the stomach through the choledochoduodenostomy.
Fig. 3 Occlusion cholangiogram
showing the intrahepatic biliary tree. Note the balloon located above the
choledochoduodenostomy.
Fig. 4 Sphincterotomy for
extraction of the multiple, large stones and biliary sludge.
The “sump syndrome” is rarely seen in the present time.
This syndrome is a complication of a choledochoenterostomy and results from the
accumulation of debris, which enters into the CBD from the duodenum
[1]
[2]. Often, the debris cannot
escape distally through the intact ampulla of Vater and starts accumulating
within the distal, nonfunctioning CBD, resulting in the creation of a
“sump”. The debris induces the formation of sludge and stones,
which can occlude the entire CBD. Clinically, patients present with recurrent
attacks of abdominal pain or cholangitis [2]
[3]. The sump syndrome can be treated surgically by creating
a Roux-en-Y hepaticojejunostomy and by endoscopy by performing a biliary
sphincterotomy and extracting the debris from the CBD [2]
[3].
Endoscopy_UCTN_Code_CCL_1AZ_2AK
