A 71-year-old man presented with a history of acute postprandial right upper quadrant pain. Initial investigations confirmed pyrexia and elevated bilirubin. His medical history was notable for a laparoscopic cholecystectomy for symptomatic cholelithiasis 6 years ago. This was complicated by postoperative choledocholithiasis requiring diagnostic endoscopic ultrasound and therapeutic endoscopic retrograde cholangiopancreatography (ERCP). At the time of postoperative ERCP, complete clearance of the biliary tree was confirmed on fluoroscopy.
At the time of current acute presentation, an abdominal CT demonstrated moderate biliary dilatation down to the level of a thin metallic intraluminal density within the common bile duct (CBD) (Figure 1). On comparison with a chest CT performed 1 month earlier for assessment of an organizing pneumonia, a cholecystectomy clip had since migrated from the gallbladder fossa through the cystic duct stump into the CBD. After admission, total bilirubin increased from 30 to 66 μmol/L, γ-glutamyltransferase to 852 U/L, alkaline phosphatase to 546 U/L, alanine aminotransferase to 312 U/L, and aspartate transaminase to 241 U/L. His temperature was 38.5°C, and his white blood cell count was 6.0 × 109 cells/L. Suspecting ascending cholangitis secondary to an obstructing migrated cholecystectomy clip, fluid resuscitation and broad-spectrum antibiotic coverage were commenced and ERCP was performed.
ERCP confirmed a linear radiopacity with a surrounding filling defect within the lower CBD (Figure 2). Balloon sphincteroplasty was performed, and the cholecystectomy clip and adherent sludge were successfully removed via a balloon sweep (Figure 3). The clip was then extracted from the patient by using clip forceps (Figure 4).
Postcholecystectomy clip migration was first described in the literature in 1978.1 Clips may migrate via the biliary tree, via a duodenal ulcer, or even by a clip embolism.2 Risk factors for postcholecystectomy clip migration include cholecystectomies with more than 4 surgical clips, previous complicated gallstone disease, inaccurate clip placement, and distorted anatomy.2 The pathophysiology is thought to be related to cystic stump necrosis and movement of the clip to a low-pressure system via the CBD.3 Management options include ERCP, percutaneous biliary cholangiogram (PTC) with biliary drain placement, and surgery.2,4 ERCP is the preferred mode of removal because even when not initially successful, it can allow for delayed spontaneous passage.2 The patient's blood cultures were negative, and he was discharged home on a course of antibiotics with resolution of all symptoms.
Author contributions: D. Sanders wrote the manuscript, reviewed the literature, and is the article guarantor. T. Murray provided the images. MF Byrne reviewed the manuscript.
Financial disclosure: MF Byrne is the CEO and shareholder of Satis Operations Inc.
Informed consent was obtained for this case report.
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2. Chong VH, Chong CF. Biliary complications secondary to post-cholecystectomy clip migration: A review of 69 cases. J Gastrointest Surg. 2010;14(4):688–96.
3. Chong VH, Yim HB, Lim CC. Clip-induced biliary stone. Singapore Med J. 2004;45(11):533–5.
4. Martinez J, Combs W, Brady PG. Surgical clips as a nidus for biliary stone formation: Diagnosis and therapy. Am J Gastroenterol. 1995;90(9):1521–4.