Published online Jul 16, 2014. doi: 10.4253/wjge.v6.i7.328
Revised: April 25, 2014
Accepted: June 10, 2014
Published online: July 16, 2014
Processing time: 126 Days and 19.3 Hours
Intraductal papillary mucinous neoplasm (IPMN) of the bile duct is still rare and not yet understood despite of its increased incidence and similar clinicopathologic characteristics compared with IPMN of the pancreas. The fistula formation into other organs can occur in IPMN, especially the pancreatic type. To our knowledge, only two cases of IPMN of the bile duct with a choledochoduodenal fistula were reported and we have recently experienced a case of IPMN of the bile duct penetrating into two neighboring organs of the stomach and duodenum presenting with abdominal pain and jaundice. Endoscopy showed thick mucin extruding from two openings of the fistulas. Endoscopic suction of thick mucin using direct peroral cholangioscopy with ultra-slim endoscope through choledochoduodenal fistula was very difficult and ineffective because of very thick mucin and next endoscopic suction through the stent after prior insertion of biliary metal stent into choledochogastric fistula also failed. Pathologic specimen obtained from the proximal portion of the choledochogastric fistula near left intrahepatic bile duct through the metal stent showed a low grade adenoma. The patient declined the surgical treatment due to her old age and her abdominal pain with jaundice was improved after percutaneous transhepatic biliary drainage with the irrigation of N-acetylcysteine three times daily for 10 d.
Core tip: An intraductal papillary mucinous neoplasm of the bile duct with combined fistula formation into the stomach and the duodenum initially presented with jaundice and abdominal pain was introduced and after failed attempts of endoscopic suction of thick mucin through the two fistulas to resolve the jaundice, the patient’s symptom was successfully resolved after the irrigations of N-acetylcysteine three times daily via after percutaneous transhepatic biliary drainage tube for 10 d.