Sharpnel splinter in the common bile duct

TL;DR

A 59-year-old man developed jaundice due to a shrapnel splinter in his bile duct, 7 years after a combat injury.

Contribution

This is the first documented case of a shrapnel splinter causing obstructive jaundice in a combat-injured patient from Syria.

Findings

A shrapnel splinter in the common bile duct caused obstructive jaundice 7 years after a combat injury.

This case highlights the need to consider foreign bodies as a cause of jaundice in post-combat injury patients.

Abstract

Foreign bodies are a rare cause of obstructive jaundice. In this case report, we present the case of a 59-year-old male who presented with abdominal pain and obstructive jaundice, which was later found out to be caused by an impacted shrapnel splinter in the common bile duct 7 years after a combat injury. To our knowledge, this is the first documented case from Syria. This case report is a reminder that impacted foreign bodies should be considered as a potential cause of obstructive jaundice in patients with previous combat injury.

Figures

Endoscopic retrograde cholangiopancreatography showing a foreign body (The arrow) in the CBD before sphincterotomy.

Endoscopic retrograde cholangiopancreatiography after extraction of the foreign body following sphincterotomy and placement of a plastic stent.

The shell splinter as a foreign body (black arrow) in the common bile duct as seen on endoscopic retrograde cholangiopancreatography.

Splinter after extraction by upper Esophagogastroduodenoscopy (EGD).

Tables

Table 1. Lab work

Test	On admission	Discharge	Normal limits	Unit
WBC	6500	9800	4500–10 500	/mm3
Hemoglobin	13.4	14	12–16	g/dl
Platelets	132	254	150–450	X 1000mm3
Serum Amylase	1042		290	U/L
Urea	20		15–54	mg/dl
Creatinine	0.6		0.5–1.3	mg/dl
ALT	90		5–45	U/L
AST	53		8–40	U/L
Total Bilirubin	6.8		0.5–1.2	mg/dl
Direct Bilirubin	5.9		0–0.3	mg/dl
Alp	389		UP TO 290	U/L
Ggt	551		0–50	U/L
Pt/INR	49%/1.5	60%/1.3	70%
Glucose	100	105	74–106	mg/dl
Crp	71.3	6
Na	132	138	132–138
K	3.3	4.1	3.5–5
Ca19-9	632			U/milliliter

Table 2. Characteristics of the reported cases of missiles in the biliary tree from combat injury

Reference	Positive symptoms and signs on admission	Type of foreign body	Age (yr)/gender	Original injury	Latent period	Site of migration
Eghuchi [1]	Icterus, pruritus	Shrapnel splinter	60/M	Right thoracic cavity	36 yr	CBD
Kamona [2]	Abdominal pain	Bullet	14/M	Liver parenchyma	4 mo	CBD
Silvermann [3]	Icterus, fever, abdominal pain	Shrapnel	75/M	RUQ	Initial injury in World War 2	CBD
Mitchell [4]	Fever, weight loss, nausea, vomiting, abdominal pain icteric sclera	Shrapnel splinter	64/M	RUQ	44 yr	CBD
Hussain [5]	Jaundice, right hypochondrial pain, vomiting, fever, weakness, fatigue and weight loss	Bullet	26/M	Right lobe of the liver	9 yr	CHD
Klein [6]	Jaundice, abdominal pain	Shell splinter	44/M	Foramen of winslow	9 yr	direct penetration to CBD
Rescorla [7]	Abdominal pain in RUQ2, Scleral icterus	Bullet	8/F	Left lobe of the liver	22 mo	CHD
Krontiris [8]	Fever, jaundice, acholic stool, anorexia, malaise, and weakness, abdominal pain in RUQ	Cap of a bullet	36/M	Right lower thorax	13 yr	CBD
Gottschalk [9]	Abdominal pain and tenderness in RUQ, jaundice	Shell splinter	69/M	-	49 yr	CBD
Somi MH [10]	Jaundice, abdominal pain in RUQ	Shrapnel splinter	42/M	RUQ and right thorax	23 yr	CBD
Present case	Jaundice, pain in the RUQ (right upper quadrant) of the abdomen and epigastrum	Shrapnel splinter	59/M	Abdomen	7 yr	CBD

Full text

Introduction

Foreign bodies in the biliary tract are a rare cause of obstructive jaundice. Therefore, they usually do not receive much attention. Such foreign bodies include: T- tubes, vessel clips, fish bones, bullets and sharpnel splinters. This report describes the case of a 59-year-old male who presented with obstructive jaundice caused by an impacted shrapnel in the common bile duct 7 years after the initial injury. To our best knowledge, this is the first documented case from syria. We also report on the findings on Endoscopic Retrograde Cholangiopancreatography (ERCP), discuss the management plan and point out to the idea that shrapnel splinters in the common bile duct should be taken into consideration as a differential diagnosis in patients who present with symptoms suggestive of obstructive jaundice and who have a history of combat injury.

Case presentation

A 59-year-old male presented with a two-week history of jaundice and tenderness in the right upper quadrant (RUQ) of the abdomen and epigastrum, with radiation to the back. He did not suffer from fever or diarrhea, He sustained an abdominal injury during the conflict in Syria, and several sharpnel splinters settled in his abdomen, He has no medical history, and his surgical history extracting a military shrapnel from abdominal cavity, and no history of medication.

On physical examination, the patient had icterus, jaundice, and tenderness in the RUQ. A scar on the abdominal midline was also noted. Lab work was as shown on Table 1.

On abdominal ultrasonography, the gallbladder was normal, and the diameter of the intrahepatic ducts was within normal limits. However, the common bile duct was dilated (diameter = 100 millimeters). Based on the laboratory and radiological findings. Cholangiocarcinoma was suspected.

This dilation was presumed to be the probable cause of the patient’s symptoms. Therefore, we decided to perform a diagnostic (ERCP).

During the ERCP, we noted a filling defect in the proximal portion of the common bile duct (CBD) that was caused by an obstructive object.

The obstructive object roughly measured (6 × 7 millimeters) (Fig. 1).

Endoscopic retrograde cholangiopancreatography showing a foreign body (The arrow) in the CBD before sphincterotomy.

Endoscopic retrograde cholangiopancreatiography after extraction of the foreign body following sphincterotomy and placement of a plastic stent is shown in (Fig. 2).

Endoscopic retrograde cholangiopancreatiography after extraction of the foreign body following sphincterotomy and placement of a plastic stent.

We performed a sphincterotomy and extracted the obstructive object with a post-dilation balloon as shown in (Fig. 3).

The shell splinter as a foreign body (black arrow) in the common bile duct as seen on endoscopic retrograde cholangiopancreatography.

A stone extraction basket was inserted using Esophagogastroduodenoscopy (EGD) as shown in (Fig. 4).

Splinter after extraction by upper Esophagogastroduodenoscopy (EGD).

Discussion

Biliary stones are not the only cause of obstructive jaundice. There are a variety of predisposing factors, such as narrowing of the anastomoses between the biliary tract and the duodenum after surgical interventions, malignant and benign strictures. Foreign bodies in the CBD are a rare cause. However, it should be considered as a cause, especially in people with a history of a combat injury, regardless of the initial entry point of the sharpnel splinters. The entrance point of the shrapnel splinters is not limited to the abdomen. There have been cases where the entry point was the thoracic cavity [1].

Although, obstructive jaundice is the most common symptom of foreign bodies in the CBD, symptoms may be limited to abdominal pain [2].

Chronic obstruction of the biliary tract may be complicated by sclerosing cholangitis [3].

We note from the cases shown in Table 2 that symptoms caused by foreign bodies in the CBD has a latency period ranging from months to years before they appear.

Foreign bodies in the CBD may sometimes present with symptoms indicative of malignancy such as weight loss [4, 5]. In our case, the patient had elevated CA 19-9 levels.

Summary

Foreign bodies in the biliary tract that cause of obstructive jaundice miscellaneous, that a missed gauze in the abdominal cavity after surgery on abdominal cavity, Therefore, it is important to take the patient’s medical history carefully to determine the cause of obstructive jaundice.