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Acute Cholangitis following Biliary Obstruction after Duodenal OTSC Placement in a Case of Large Chronic Duodenocutaneous Fistula.

Alastal Y, Hammad TA, Nawras M, Khalil BW, Alaradi O, Nawras A - Case Rep Gastrointest Med (2015)

Bottom Line: Over-the-Scope Clip system, also called "Bear Claw," is a novel endoscopic modality used for closure of gastrointestinal defect with high efficacy and safety.Bear Claw clip was used for closure of this fistula.Acute cholangitis due to papillary obstruction is a potential complication of Bear Claw placement at the dome of the duodenal stump (afferent limb) in patient with Billroth II surgery due to its close proximity to the major papilla.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, University of Toledo Medical Center, Toledo, OH 43614, USA.

ABSTRACT
Over-the-Scope Clip system, also called "Bear Claw," is a novel endoscopic modality used for closure of gastrointestinal defect with high efficacy and safety. We present a patient with history of eosinophilic gastroenteritis and multiple abdominal surgeries including Billroth II gastrectomy complicated by a large chronic duodenocutaneous fistula from a Billroth II afferent limb to the abdominal wall. Bear Claw clip was used for closure of this fistula. The patient developed acute cholangitis one day after placement of the Bear Claw clip. Acute cholangitis due to papillary obstruction is a potential complication of Bear Claw placement at the dome of the duodenal stump (afferent limb) in patient with Billroth II surgery due to its close proximity to the major papilla.

No MeSH data available.


Related in: MedlinePlus

Bear Claw clip placed in the afferent loop of the Billroth II with mild edema surrounding this region.
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Related In: Results  -  Collection


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fig4: Bear Claw clip placed in the afferent loop of the Billroth II with mild edema surrounding this region.

Mentions: 28-year-old female patient with history of eosinophilic gastroenteritis and multiple abdominal surgeries including Billroth II gastrectomy referred to our hospital for treatment of duodenocutaneous fistula. She had large chronic duodenocutaneous fistula measuring about 0.8 cm in diameter extending from Billroth II afferent limb to the abdominal wall. Multiple previous attempts to close the fistula have failed. The patient was scheduled for elective cutaneous and enteric closure of the fistula with fibrin glue and Bear Claw endoclip placement, respectively. During the procedure, a pediatric colonoscope was introduced into the blind enteric limb; the major papilla was identified 3-4 cm proximal to the dome of the blind limb. India ink was injected through the cutaneous orifice of the fistula to localize the internal orifice in the dome of the blind limb (Figure 1). A 0.035 inch × 450 cm guide wire was introduced through the cutaneous orifice and advanced into the blind enteric limb under endoscopic and fluoroscopic guidance; the guide wire was grasped with rat tooth biopsy forceps. The pediatric colonoscope was then withdrawn with the guide wire. Subsequently, the scope was changed to an adult gastroscope. An 11/6 t Bear Claw endoclip was secured on the tip of the gastroscope; then the gastroscope with the Bear Claw endoclip was reintroduced over the guide wire into the afferent duodenal limb. The enteric orifice of the fistula was suctioned inside the cap of the Bear Claw with the wire still inside the fistula and scope channel (Figure 2). Once the fistula site at the dome of the afferent limb was seen filling the cap, the guide wire was removed and the clip was deployed successfully closing the enteric orifice of the fistula (Figure 3) (the attached video demonstrates the key portions of Bear Claw placement procedure in our patient). The position of the Bear Claw endoclip was confirmed endoscopically and fluoroscopically. Subsequently, the cutaneous orifice was identified and injected with fibrin glue. The patient tolerated the procedure well without immediate complications and was discharged home for outpatient follow-up. On the next day, the patient developed fever, jaundice, changes in mental status, and abdominal pain. Her vital signs were as follows: blood pressure: 124/68, pulse rate: 151 beats per minutes, temperature: 40.1°C, and respiratory rate: 28 per minute. Abdominal examination revealed diffuse tenderness. Laboratory work showed white blood cell counts of 5 × 109/L (normal range: 4–10 × 109/L), direct bilirubin of 3.3 mg/dL (normal range: 0–0.3 mg/dL), and Alkaline phosphatase, aspartate, and alanine aminotransferase levels of 255 U/L (normal range: 45–115 U/L), 272 U/L (normal range: 8–48 U/L), and 134 U/L (normal range: 7–55 U/L), respectively. Amylase and lipase were normal. Abdominal ultrasound revealed dilation of the common bile duct (1.2 cm) with intrahepatic biliary dilation. Abdominal CT scan showed mild edema surrounding the endoclip in the afferent loop of the Billroth II with no definite abscess or fluid collection (Figure 4). The pancreas was normal. HIDA scan suggested biliary obstruction. The patient was diagnosed with acute cholangitis secondary to biliary obstruction due to Bear Claw placement close to the major papilla grasping adjacent tissue. She was managed with empirical antibiotics and supportive care. Upon patient's family preference, percutaneous transhepatic cholangiography (PTC) was done rather than ERCP. PTC showed diffuse dilation of the biliary tree down to the papilla. Percutaneous transhepatic drainage was performed and the guide wire was advanced into the duodenum through the major papilla adjacent to the Bear Claw clip which was causing partial obstruction (Figure 5). An 8 French pigtail catheter was placed down to the duodenum. As a result, the patient had clinical and laboratory improvement. Five months later, the fistula did not close completely and the patient underwent laparotomy repair which involved dissection of the fistula from the surrounding adhesions and duodenotomy around it, followed by excision of the tract and the attached duodenal wall. The Bear Claw was not palpable on the duodenal wall during surgery which suggested spontaneous migration before surgery. The duodenal stump was sutured and covered with omental patch. The patient had an uneventful postoperative recovery with no recurrence of fistula after surgery.


Acute Cholangitis following Biliary Obstruction after Duodenal OTSC Placement in a Case of Large Chronic Duodenocutaneous Fistula.

Alastal Y, Hammad TA, Nawras M, Khalil BW, Alaradi O, Nawras A - Case Rep Gastrointest Med (2015)

Bear Claw clip placed in the afferent loop of the Billroth II with mild edema surrounding this region.
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4491398&req=5

fig4: Bear Claw clip placed in the afferent loop of the Billroth II with mild edema surrounding this region.
Mentions: 28-year-old female patient with history of eosinophilic gastroenteritis and multiple abdominal surgeries including Billroth II gastrectomy referred to our hospital for treatment of duodenocutaneous fistula. She had large chronic duodenocutaneous fistula measuring about 0.8 cm in diameter extending from Billroth II afferent limb to the abdominal wall. Multiple previous attempts to close the fistula have failed. The patient was scheduled for elective cutaneous and enteric closure of the fistula with fibrin glue and Bear Claw endoclip placement, respectively. During the procedure, a pediatric colonoscope was introduced into the blind enteric limb; the major papilla was identified 3-4 cm proximal to the dome of the blind limb. India ink was injected through the cutaneous orifice of the fistula to localize the internal orifice in the dome of the blind limb (Figure 1). A 0.035 inch × 450 cm guide wire was introduced through the cutaneous orifice and advanced into the blind enteric limb under endoscopic and fluoroscopic guidance; the guide wire was grasped with rat tooth biopsy forceps. The pediatric colonoscope was then withdrawn with the guide wire. Subsequently, the scope was changed to an adult gastroscope. An 11/6 t Bear Claw endoclip was secured on the tip of the gastroscope; then the gastroscope with the Bear Claw endoclip was reintroduced over the guide wire into the afferent duodenal limb. The enteric orifice of the fistula was suctioned inside the cap of the Bear Claw with the wire still inside the fistula and scope channel (Figure 2). Once the fistula site at the dome of the afferent limb was seen filling the cap, the guide wire was removed and the clip was deployed successfully closing the enteric orifice of the fistula (Figure 3) (the attached video demonstrates the key portions of Bear Claw placement procedure in our patient). The position of the Bear Claw endoclip was confirmed endoscopically and fluoroscopically. Subsequently, the cutaneous orifice was identified and injected with fibrin glue. The patient tolerated the procedure well without immediate complications and was discharged home for outpatient follow-up. On the next day, the patient developed fever, jaundice, changes in mental status, and abdominal pain. Her vital signs were as follows: blood pressure: 124/68, pulse rate: 151 beats per minutes, temperature: 40.1°C, and respiratory rate: 28 per minute. Abdominal examination revealed diffuse tenderness. Laboratory work showed white blood cell counts of 5 × 109/L (normal range: 4–10 × 109/L), direct bilirubin of 3.3 mg/dL (normal range: 0–0.3 mg/dL), and Alkaline phosphatase, aspartate, and alanine aminotransferase levels of 255 U/L (normal range: 45–115 U/L), 272 U/L (normal range: 8–48 U/L), and 134 U/L (normal range: 7–55 U/L), respectively. Amylase and lipase were normal. Abdominal ultrasound revealed dilation of the common bile duct (1.2 cm) with intrahepatic biliary dilation. Abdominal CT scan showed mild edema surrounding the endoclip in the afferent loop of the Billroth II with no definite abscess or fluid collection (Figure 4). The pancreas was normal. HIDA scan suggested biliary obstruction. The patient was diagnosed with acute cholangitis secondary to biliary obstruction due to Bear Claw placement close to the major papilla grasping adjacent tissue. She was managed with empirical antibiotics and supportive care. Upon patient's family preference, percutaneous transhepatic cholangiography (PTC) was done rather than ERCP. PTC showed diffuse dilation of the biliary tree down to the papilla. Percutaneous transhepatic drainage was performed and the guide wire was advanced into the duodenum through the major papilla adjacent to the Bear Claw clip which was causing partial obstruction (Figure 5). An 8 French pigtail catheter was placed down to the duodenum. As a result, the patient had clinical and laboratory improvement. Five months later, the fistula did not close completely and the patient underwent laparotomy repair which involved dissection of the fistula from the surrounding adhesions and duodenotomy around it, followed by excision of the tract and the attached duodenal wall. The Bear Claw was not palpable on the duodenal wall during surgery which suggested spontaneous migration before surgery. The duodenal stump was sutured and covered with omental patch. The patient had an uneventful postoperative recovery with no recurrence of fistula after surgery.

Bottom Line: Over-the-Scope Clip system, also called "Bear Claw," is a novel endoscopic modality used for closure of gastrointestinal defect with high efficacy and safety.Bear Claw clip was used for closure of this fistula.Acute cholangitis due to papillary obstruction is a potential complication of Bear Claw placement at the dome of the duodenal stump (afferent limb) in patient with Billroth II surgery due to its close proximity to the major papilla.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, University of Toledo Medical Center, Toledo, OH 43614, USA.

ABSTRACT
Over-the-Scope Clip system, also called "Bear Claw," is a novel endoscopic modality used for closure of gastrointestinal defect with high efficacy and safety. We present a patient with history of eosinophilic gastroenteritis and multiple abdominal surgeries including Billroth II gastrectomy complicated by a large chronic duodenocutaneous fistula from a Billroth II afferent limb to the abdominal wall. Bear Claw clip was used for closure of this fistula. The patient developed acute cholangitis one day after placement of the Bear Claw clip. Acute cholangitis due to papillary obstruction is a potential complication of Bear Claw placement at the dome of the duodenal stump (afferent limb) in patient with Billroth II surgery due to its close proximity to the major papilla.

No MeSH data available.


Related in: MedlinePlus