A 67-year-old female with a history of open cholecystectomy and choledochoduodenostomy for gallstone disease 22 years prior presented with right hypochondriac pain, high-grade fever with chills, and vomiting. She reported no history of jaundice, pruritus, or clay-colored stool. Her general physical and systemic examinations were unremarkable. Routine investigations revealed leukocytosis (14,500/µL) and elevated alkaline phosphatase levels (386 U/L), with normal transaminases and bilirubin.
An emergency ultrasound identified a heterogeneously enhancing space-occupying lesion in segments IV and VIII of the liver. Subsequent computed tomography scan showed cholangitic abscesses within the liver, dilated intrahepatic biliary radicles and common bile duct (CBD) with pneumobilia, and mixed-density contents in CBD lumen suggestive of food residue. Additionally, a large fistulous communication was observed between CBD and duodenum ([Figs. 1a, 1b] and [2a]). All above features were suggestive of choledochoduodenostomy with sump syndrome with cholangitis. Esophagogastroduodenoscopy revealed a large opening of the choledochoduodenostomy in the anterior wall of the first part of duodenum, with food residue visible across the opening in CBD ([Fig. 2b]). Endoscopic retrograde cholangiopancreatography (ERCP) was performed under propofol sedation using triple lumen sphincterotome (CleverCut 3 V, Olympus) and guidewire (VisiGlide, Olympus, 0.025 inch) negotiated into left intrahepatic duct. CBD clearance was performed using a triple lumen extraction balloon (Multi-3V Plus, Olympus), successfully extracting food residue and a 7Fr × 7 cm double pigtail stent was placed in CBD. Following intervention, the patient's symptoms resolved, and she was advised to follow up regularly.
Fig. 1 Contrast enhanced computed tomography image in postro-venous phase shows dilated common bile duct (CBD), dilated intrahepatic biliary radicals (IHBRD) in right lobe of liver with pneumobillia and mottled contents (arrow) in common bile duct suggestive of food particles, figure 1b- shows shows suspicious fistulous communication (arrow) of duodenum with common bile duct.
Fig. 2 Axial contrast enhanced computed tomography image in porto-venous phase shows pneumobillia (arrow) with dilated central intrahepatic biliary radicals, figure 2b endoscopic image showing large opening of choledochoduodenostomy in anterior wall of first part of duodenum with food debris and sludge (arrow) seen across the opening on combine bile duct.
Sump syndrome is a rare complication of choledochoduodenostomy, which results from the transformation of the bile duct distal to choledochoduodenostomy anastomosis into a poorly drained reservoir, prone to accumulation of debris serving as nidus for bacterial proliferation.[1] Caroli-Bosc et al in their retrospective analysis of 30 case of sump syndrome have reported food-debris accumulation as the most common cause of biliary obstruction followed by calculi.[2] The management involves ERCP with extraction of debris from the CBD and/or Roux-en-Y hepaticojejunostomy.[2]
