Acute obstructive cholangitis caused by barium refluxed into the common bile duct through endoprosthesis.

cause of early gastric cancer (UICC, stage II) and pancreatic cancer (UICC, Stage III). An endoprosthesis, 7 Fr in size, had been placed for obstructive jaundice due to pancreatic cancer in another hospital. La− boratory data on admission showed slight elevation of total bilirubin (1.7 mg/ dL). High−grade fever and remarkable jaundice developed (total bilirubin, 6.1 mg/dL) 6 days after an upper gastroin− testinal series for evaluation of gastric cancer. We considered acute obstructive cholangitis due to occlusion of the endo− prosthesis, and performed endoscopic retrograde cholangiopancreatography. A radiograph taken while retrieving the endoprosthesis prior to a cholangiogram showed barium at the common bile duct as well as transverse colon (l" Fig. 1). Al− though we tried to remove the barium by basket catheter after retrieving the endo− prosthesis, the basket catheter could not grasp enough of the barium (l" Fig. 2 a). In spite of the presence of a biliary stric− ture due to pancreatic carcinoma, the bal− loon catheter was able to remove the bar− ium to the distal side of the stricture little by little. Surprisingly, however, inflation maneuver of the balloon catheter result− ed in migration of the proximal barium into the biliary trees (l" Fig. 2 b). Finally, a 7 Fr nasobiliary drainage catheter was placed (l" Fig. 2 c). It took 4 days for the nasobiliary drainage catheter to comple− tely clean the barium from the biliary trees (l" Fig. 2 d). The reason why barium refluxed into the common bile duct through endopros− thesis remains unknown. This complica− tion is extremely rare and has not been reported before. In the patients who have a resectable tumor, placement of a 7 Fr nasobiliary drainage catheter might be the first choice for obstructive jaundice by barium through endoprosthesis, be− cause the basket catheter is not effective and the balloon catheter leads to migra− tion of barium into proximal biliary trees. On the contrary, in patients who have an unresectable tumor, placement of a self− expandable metallic stent would be a bet− ter choice. To avoid mistreatment, endoscopists should be aware of this extremely rare barium−related complication.