A 52-year-old woman was admitted to our institute with abdominal pain in the right
upper quadrant and anorexia for a few days. In 1995, she had undergone a lithotripsy
using percutaneous cholangioscopy, because of intrahepatic bile duct stones. The patient
had refused resection of the left lateral segment of the liver. A self-expandable
metal stent covered with polytetrafluoethylene had also been inserted in the stricture
site in the left main intrahepatic bile duct, to avoid recurrent cholangitis and intrahepatic
bile duct stone. Now, 6 years later, she had developed abdominal pain in the right
upper quadrant associated with an elevated serum level of aminotransferase and alkaline
phosphatase (aspartate aminotransferase 56 IU/l (normal range 0 - 37 IU/l); alanine
aminotransferase 45 IU/l (normal range 0 - 41 IU/l); alkaline phosphatase 643 IU/l
(normal range 53 - 128 IU/l). Endoscopic retrograde cholangiopancreatography revealed
the dilated extrahepatic bile duct and left intrahepatic bile duct to be without stricture,
and also the presence in the distal common bile duct of a large elongated freely mobile
filling defect, suggestive of common bile duct stone containing a metal mesh (Figure
[1]). After successful endoscopic sphincterotomy, mechanical lithotripsy was performed
because of the large size of the stone. The stone was soft and dark brown in color
with the metal stent extruding from the ampulla of Vater along with common bile duct
stone fragments (Figure [2]). After complete removal of the stone, the serum level of hepatic enzymes returned
to normal, and the patient has remained asymptomatic. An intrahepatic biliary stricture
may not only limit the clearance of stones but also contribute to the recurrence of
stones and cholangitis. Published reports of the intrahepatic use of metallic stents
for hepatolithiasis and biliary stricture remain limited. Jeng et al. [1] reported that metallic stent placement seemed to be an effective and well-tolerated
treatment for complicated refractory hepatic ductal strictures with hepatolithiasis.
The formation of biliary tract stones around surgically introduced foreign material
has been well documented. IT is reported that 30 % of recurrent stones after cholecystectomy
contained nonabsorbable suture material in their nuclei [2]. Metallic surgical clips have migrated into the biliary tract and acted as a nidus
for stone formation [3]
[4]. Biliary stasis and bacterial overgrowth resulting in bacterial degradation of bile
were contributing factors in the above cases [5].
Figure 1 Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated dilated extrahepatic
bile and left intrahepatic bile ducts. Note the large elongated filling defect with
the metal stent centrally in the extrahepatic bile duct.
Figure 2 The exposed area of metallic stent with the conglomerated fragments of stone, and
the distorted covered area of the stent with polytetrafluoethylene material, after
washing.
