Year : 1995 | Volume
: 1 | Issue : 2 | Page : 97--101
Role of ERCP in diagnosis and management of "clip cholangitis": Case report and review of the literature
Fazal I Khawaja
Gastroenterology Section, King Fahad Hospital Al Madina AI Munawara, Saudi Arabia
Fazal I Khawaja
King Fahad Hospital, Al Madina Al Munawara
|How to cite this article:|
Khawaja FI. Role of ERCP in diagnosis and management of "clip cholangitis": Case report and review of the literature.Saudi J Gastroenterol 1995;1:97-101
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Khawaja FI. Role of ERCP in diagnosis and management of "clip cholangitis": Case report and review of the literature. Saudi J Gastroenterol [serial online] 1995 [cited 2020 Feb 21 ];1:97-101
Available from: http://www.saudijgastro.com/text.asp?1995/1/2/97/34048
Foreign bodies in the biliary tree act as a nidus for stone formation ,, and may present with biliary colic, acute cholangitis, pancreatitis and/or obstructive jaundice. Metallic clips are commonly-used during cholecystectomy for hemostasis and for closure of cystic duct stump. They are readily visible on abdominal radiography and generally cause no clinical problem. Rarely, a clip placed on the cystic duct stump erodes into the common bile duct (CBD) and serves as a nidus for stone formation ,,,,,,, . Recently, cases of clip migration into the CBD following laparoscopic cholecystectomy have been reported , . This report describes a patient who presented with acute cholangitis ten years after open cholecystectomy. The abnormal position of one of the clips suggested the possibility of its intraductal location. ERCP clearly demonstrated the presence of a metallic clip in the center of a common bile duct stone. The "stone clip" combination was successfully removed endoscopically.
A 57-year-old male was admitted with one day history of severe right upper quadrant pain, fever and shaking chills. He had noticed that his urine had become dark. He did not complain of any cough or urinary symptoms. Patient had a vagotomy done for chronic peptic ulcer disease 15 years ago and a cholecystectomy done 10 years prior to admission. Unfortunately details of the surgeries were not available; however, there was no history suggestive of a postoperative T- tube drain. There were no other medical or surgical problems. There were no episodes of severe biliary or right upper quadrant pain since the cholecystectomy.
On examination, the patient was febrile, temperature was 38.5°C, blood pressure was 150/90 mm Hg, pulse 110/min. Scleral icterus was present. There were no spider nevi, palmar erythema or astrexis. Patient was fully conscious and oriented. Heart and lungs were within normal limits. The abdomen was soft and scaphoid. Scars of previous surgeries were noted, bowel sounds were present. There was no evidence of free fluid in the abdomen. The liver edge was slightly tender and was felt just below the right costal margin. Spleen was not palpable. There was no clubbing or pedal edema. Laboratory studies showed a hemoglobin of 16.0 g/ dl, a white cell count of 18,500/mm 3 with 90% polymorphs, platelets were 180,000/mm 3 . Urea, creatinine and electrolytes were within normal limits. Amylase was 150 LU (normal). Total bilirubin was 100 mmol/L, direct bilirubin 80 mmol/L, ALT 120 I.U, AST 110 LU, alkaline phosphatase was 350 LU, total protein was 75 g/L and albumin of 38 g/L. The coagulation profile was normal. Multiple metallic clips were noticed on plain roentgenogram of the abdomen. Some of these clips were present at the esophageal hiatus while some others were located in the right upper quadrant. Their position was considered to be consistent with the previously-performed vagotomy and cholecystectomy. One of the clips was lying oblique along the transverse process of the first lumbar vertebra [Figure 1]. It was suspected that this clip might be inside the common bile duct. Ultrasound examination of the abdomen failed to reveal any dilatation of the biliary tree; however, many artifacts were present because of surgical metallic clips. The patient was kept NPO. Parenteral fluids, ampicillin and gentamycin were started after taking blood cultures. On the following day, an ERCP was performed using the Olympus JK 10 duodenoscope. The duodenum was markedly deformed and advancement to the second part of duodenum was achieved with difficulty. The papilla was normal and dirty; infected bile was demonstrated coming out of a somewhat patulous papillary orifice. Cannulation was easy. The common bile duct was normal in size. A metallic surgical clip (nidus) in the center of an oval-shaped filling defects (stone) was noted inside the common bile duct. During manipulation with the catheter tip the stone broke into two fragments. The clip remained attached to one of the fragments. [Figure 2]. The stone with the clip could be moved freely inside the CBD lumen. The open limbs of the clip were seen facing different directions. An endoscopic sphincterotomy was performed in a standard fashion. There were no complications. However, the patient became restless and pulled out the endoscope. No attempt could be made to remove the stone from the CBD. A plain radiograph of the abdomen was done at the end of the procedure. The clip was seen inside the air column outlining the biliary tree. It was again seen inside lying obliquely along the transverse process of the first lumbar vertebra. [Figure 3]. A repeat radiograph after 24 hours revealed pneumobilia. The previously noted clip was missing from the biliary tree. Instead it was seen lying horizontally at the left side of the abdomen in the region of the descending colon. [Figure 4]. The patient passed the clipstone the natural way. He was discharged from the hospital the next day and has not returned for follow-up since then.
Various types of foreign bodies may lodge in the biliary tree. Parasitic invasion of the biliary tree is common in certain parts of the world ,, . The parasites most frequently involved include: ascaris lumbricoides  , clonorchis sinensis, fasciola hepatica  , and echinococcus granulosus hepatic cyst rupturing into the bile ducts  . Rarely, missiles from penetrating wounds end up in the biliary tree. Ingested material might enter the biliary tract via spontaneous or previously-fashioned bilioenteric fistulas. Postsurgical residuals are among the commonest non-parasitic foreign bodies , . Complications caused by intraductally - retained broken fragments of T-tubes, biliary drainage catheters, suture materials, and metallic hemostatic clips have been reported.
The true incidence of these postsurgical foreign bodies is difficult to establish. Usually symptoms are produced by the stones which have formed around the foreign body nidus. As most of the foreign bodies involved are not radio-opaque, these stones cannot be differentiated from the usual common bile duct stones. Unless the stones are retrieved and carefully analyzed, these "buried" foreign bodies cannot be exposed  . On the contrary, due to the radio-opaque nature of these clips, their presence is easily documented. In fact, these metallic clip-nidus stones have a characteristic cholangiographic appearance. Typically a slit-like metallic density (clip) is seen within a filling defect (stone) inside the common bile duct. Due to the similarity to the feline iris, Wu et al  proposed the term "cat's eye calculus" for such stones.
How do these clips gain entrance into the biliary tree?
One possibility is the actual slipping of the clip inside the CBD during the surgery. However, such happening is unlikely to be overlooked by the surgeon, and hence, the clip will be removed immediately. Raoul et al postulated that the failure of complete cystic duct closure due to an improperly placed clip will result in a localized bile leakage and formation of a biloma around the clip. Subsequent drainage of the biloma into the biliary tree will allow the clip to migrate inside the common bile duct  . They were able to demonstrate formation of a biloma around a clip in one of their patients. Direct erosion of the clip into the biliary tree, possibly aided by multiple endoscopic manipulations, was demonstrated by Weber et al  . In this case, a clip injury during a laparoscopic cholecystectomy resulted in an early bile duct stricture formation. The position of the clip outside the biliary tree was documented by ERCP. The stricture was dilated and an endoprosthesis was placed. Six months later, a change in the position and orientation of the clip was noted immediately before a planned replacement of the endoprosthesis. When the stents were removed, the clip moved and was seen lying freely inside the bile duct. The clip was easily removed endoscopically. No biliary leakage developed.
Only twelve cases of intrabiliary metallic clips have been documented in the English literature to date [Table 1]. Most reports describe a single case following a conventional open cholecystectomy. Only one author described a series of four cases of clips in CBD; interestingly, all his cases had undergone laparoscopic cholecystectomy . This might indicate that the problem is more likely to occur following a laparoscopic cholecystectomy and more cases might be expected in the near future. The majority of the patients presented with biliary colic with or without jaundice. Cholangitis was the second most common mode of presentation. Sometimes there was associated elevation of the serum amylase level. The time interval between the surgery and the onset of first symptoms produced by the clip was shorter (average 5.2 months) in patients who had undergone laparoscopic cholecystectomy when compared to the ones following open cholecystectomy (average 4.6 years).
In the cases following laparoscopic cholecystectomy, the clips appeared as bareclips without any significant precipitation or stone formation. The longer symptom-free interval following routine cholecystectomy probably allowed enough time for a stone to form around the clip nidus. The early recognition of these cases following a laparoscopic cholecystectomy is probably related to a more diligent watch for complications with liberal and early use of ERCP in the investigation of postcholecystectomy symptoms , . Typically the clip stone is solitary. However, a very unusual case has been reported where two typical "cat's eye" stones were demonstrated inside the common bile duct  .
Direct cholangiography is needed to confirm the diagnosis
ERCP is the single best method for diagnosis and therapy. In fact, endoscopic sphincterotomy (ES) with stone/clip removal was successful in all the cases it was attempted ,,,,,, . The majority of the clips were easily removed with the use of a balloon catheter or a basket. A mechanical lithotripsy and stone crushing was required in only two cases , . No complications related to ERCP or ES were noted in these patients. Only in the three earlier reported cases were the clip stones removed surgically.
With the explosion of laparoscopic cholecystectomy, such cases will probably be seen with increasing frequency especially during the initial learning period. Use of absorbable clips or ligation of the cystic duct and artery during laparoscopic cholecystectomy may prevent such occurrence  . Any patient presenting with abdominal pain, colic, pancreatitis, or cholangitis following a laparoscopic cholecystectomy should raise the suspicion of "Clip Colic" "Clip Cholangitis" or Clip Pancreatitis. The position of the clip on plain X-ray or any change in position or orientation, i.e. change in the direction of the open limbs of the clip, should raise a suspicion. A verticallyoriented clip lying lateral to L1-L2 vertebra is suggestive of its possible intraductal location. Ultrasound is usually not very helpful. Diagnosis is easily confirmed by ERCP. Endoscopic removal after an endoscopic sphincterotomy is easy and safe in these cases and should be the standard approach.
The author wishes to thank Ms Venice Zainab Salcedo for her secretarial assistance.
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