Cholangitis after previous bile duct surgery

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Question: An elderly male with history of cholelithiasis was "treated surgically several times" during early eighties presented with ascending cholangitis. Patient underwent an ERCP showing a small fistula in the...

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Question: An elderly male with history of cholelithiasis was "treated surgically several times" during early eighties presented with ascending cholangitis. Patient underwent an ERCP showing a small fistula in the anterior part of the duodenal bulb (A). This opening was cannulated with a balloon catheter and a 0.035-inch guidewire. Contrast injection revealed the common bile duct full with stones and debris, but no contrast was seen in the intrahepatics (B). The duodenoscope was then advanced into the second duodenum and the ampulla of Vater was cannulated with a standard sphincterotome and a guidewire. Contrast injection revealed the previous distal part of the common bile duct, but contrast now exited through the choledocoduodenostomy. By performing an occlusion cholangiogram at the proximal bile duct we were able to delineate the entire biliary tree (C). A biliary sphincterotomy was performed and large amounts of sludge could be extracted (D).

What is the diagnosis?

The “Sump Syndrome” is a rare complication of a side-to-side choledochoduodenostomy that usually presents with acute ascending cholangitis. This syndrome was first described in in 1976. Sump syndrome refers to the accumulation of food and debris entering through the choledocoduodenostomy and being collected inside of the distal bile duct. The debris cannot be excreted through the papilla due to malfunction of the sphincter of Oddi, because the main orifice of bile excretion into the duodenum becomes the choledocoduodenostomy, which is the path of leaks resistance. At one point there is so much “dirt” inside the bile duct that obstruction and infection (cholangitis) ensue. Treatment is easy: biliary sphincterotomy with cleansing of the bile ducts. However, knowledge of the sump syndrome is essential for proper recognition and treatment. Lack of knowledge of this condition may lead to incomplete or failed ERCP and persistent cholangitis or choledocolithaisis.

References: 

doi: 10.1055/s-0029-1214660

doi: 10.1016/j.gie.2016.10.031 

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