Colonoscopic Treatment of Obstructive Appendicitis Caused by Dislocation of a Biliary Stent

 

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A 65-year-old woman was admitted to the emergency room with right lower quadrant abdominal pain, nausea, vomiting, fever, and chills. She had a history of complicated cholecystectomy with secondary stenosis of the common bile duct, which was treated with biliary stents for 24 months. On physical examination, she was febrile (38.6 °C), with tenderness in the right lower quadrant and a negative psoas sign. Laboratory tests revealed a leukocytosis of 15.2 × 10⁹/l and an elevated C-reactive protein level at 8.2 mg/l. The bilirubin, alkaline phosphatase, and gamma-glutamyl transferase levels were within normal limits.

A plain abdominal radiograph showed that one of the biliary stents had migrated to the region of the ileocecal valve (Figure [1]) and an emergency colonoscopy was performed. At colonoscopy, the stent was shown to be located in the appendiceal orifice (Figure [2]) and it was removed with a snare. Instantly, the patient was pain-free, and the laboratory indices of inflammation were soon within normal limits. The biliary stents were removed and were not replaced, and the patient is doing well after a follow-up period of 9 months.

Figure 1 Plain abdominal radiograph taken on admission, showing two plastic endoprostheses which are in a satisfactory position and one stent which has migrated to the region of the ileocecal valve.

Figure 2 Endoscopic view of the cecum, showing the impacted stent in the appendiceal orifice. The stent was removed with a snare.

Stenting of the biliary duct with multiple prostheses is an established procedure for the management of benign biliary strictures [1], but proximal and distal stent migration occurs in around 5 % and 6 % of cases respectively [2]. Major complications due to distal migration are rare and most commonly consist of enteral fistulas or overt perforation [3]. To the best of our knowledge, appendicitis as a complication of biliary stent migration has not been reported previously. This case is an unusual example which illustrates the obstruction hypothesis in the pathogenesis of acute appendicitis, which accounts for the majority of cases of appendicitis [4].

Endoscopy_UCTN_Code_TTT_1AQ_2AJ

References

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D. Schwab, M. D.

Department of Medicine, University Erlangen-Nürnberg

Ulmenweg 18
91054 Erlangen
Germany

Fax: +49-9131-85-35228

Email: dieter.schwab@med1.imed.uni-erlangen.de