Asian Journal of Case Reports in Surgery

Introduction: Biliary stenting during endoscopic retrograde cholangiography (ERCP) is essential for managing biliary obstructions and leaks. It is often the preferred approach as its therapeutic advantages outweigh the relatively low risk of complications.

Case Presentation: This is a case of 83 years old gentleman who presented 2 weeks post ERCP with complaint of abdominal pain and fever. He underwent ERCP for biliary obstruction secondary to choledocholithiasis. He underwent laparotomy, stent removal, duodenal patch repair and gastrojejunostomy for duodenal perforation from biliary stent migration. The patient died day 3 post-operative due to acute coronary syndrome.

Discussion: ERCP is increasingly utilized in the management of biliary obstruction. Although ERCP related complications can occur, they remain relatively uncommon. One rare but serious complication is duodenal perforation secondary to stent migration. Nevertheless, in patient presenting with severe abdominal pain and clinical signs suggestive of acute abdomen, this diagnosis should be considered promptly to ensure timely intervention.

Conclusion: Duodenal perforation from stent migration can occur and when interventions is delayed, may lead to mortality and morbidity. Early recognition and high index of suspicion allows for early interventions and good outcomes.