Background: Recurrent choledocholithiasis after cholecystectomy presents a therapeutic challenge, particularly in patients who are not candidates for surgical intervention. Risk factors for de novo stone formation include advanced age and periampullary diverticulum. Evidence guiding preventative endoscopic management strategies remains limited, and optimal approaches to reduce recurrent cholangitis are not well defined.
Objective: To describe the clinical course, management rationale, and outcomes of recurrent ascending cholangitis managed with scheduled ERCP and serial stent exchange. Methods We reviewed the clinical presentation, laboratory data, imaging, and longitudinal procedural history of an 88-year-old male with type 2 diabetes mellitus, chronic obstructive pulmonary disease, atrial fibrillation, and prior cholecystectomy.
Results: The patient presented with altered mentation, respiratory distress, and right upper quadrant abdominal pain. Laboratory evaluation demonstrated leukocytosis (WBC 20.8 × 20.8 ×10⁹/L), cholestatic liver injury (AST 516 U/L, ALT 219 U/L, alkaline phosphatase 412 U/L), hyperbilirubinemia (2.9 mg/dL), and elevated lactate (5.28 mmol/L); blood cultures grew Escherichia coli. Imaging revealed biliary ductal dilation (15 mm) and inflammatory changes near the porta hepatis. ERCP demonstrated purulent bile, sludge, choledocholithiasis, and an intradiverticular papilla; stone extraction and stent placement were performed. Since 2015, he has undergone 36 ERCPs with stent exchanges every 6–10 weeks, with five documented episodes of ascending cholangitis since 2018. Missed scheduled ERCP was associated with recurrent infection, suggesting a temporal relationship between biliary obstruction and clinical deterioration.
Conclusion: Scheduled ERCP with serial stent exchange was used to maintain biliary drainage in a non-surgical patient. This case highlights a potential preventative strategy and underscores the need for further studies to define optimal procedural intervals, outcomes, and long-term risks.
Objective: To describe the clinical course, management rationale, and outcomes of recurrent ascending cholangitis managed with scheduled ERCP and serial stent exchange. Methods We reviewed the clinical presentation, laboratory data, imaging, and longitudinal procedural history of an 88-year-old male with type 2 diabetes mellitus, chronic obstructive pulmonary disease, atrial fibrillation, and prior cholecystectomy.
Results: The patient presented with altered mentation, respiratory distress, and right upper quadrant abdominal pain. Laboratory evaluation demonstrated leukocytosis (WBC 20.8 × 20.8 ×10⁹/L), cholestatic liver injury (AST 516 U/L, ALT 219 U/L, alkaline phosphatase 412 U/L), hyperbilirubinemia (2.9 mg/dL), and elevated lactate (5.28 mmol/L); blood cultures grew Escherichia coli. Imaging revealed biliary ductal dilation (15 mm) and inflammatory changes near the porta hepatis. ERCP demonstrated purulent bile, sludge, choledocholithiasis, and an intradiverticular papilla; stone extraction and stent placement were performed. Since 2015, he has undergone 36 ERCPs with stent exchanges every 6–10 weeks, with five documented episodes of ascending cholangitis since 2018. Missed scheduled ERCP was associated with recurrent infection, suggesting a temporal relationship between biliary obstruction and clinical deterioration.
Conclusion: Scheduled ERCP with serial stent exchange was used to maintain biliary drainage in a non-surgical patient. This case highlights a potential preventative strategy and underscores the need for further studies to define optimal procedural intervals, outcomes, and long-term risks.