P0093 - Bullets Don’t Always Travel Straight - Journey of a Lodged Bullet into the Common Bile Duct

Amit Hudgi, MD¹, Dariush Shahsavari, MD², Kuldeep Kaur. Randhawa, MBBS³, Sarabjeet Kaur, MBBS¹, Spencer Fields, MS¹, Brandon Garten, BS¹, Suraj S. Padakanti, MBBS¹, Subbaramiah Sridhar, MBBS, MPH^2
1Medical College of Georgia at Augusta University, Augusta, GA; ²Augusta University, Augusta, GA; ³Government Medical College, Brampton, ON, Canada

Introduction: Traumatic injuries to the biliary tract are uncommon and usually lead to bile leaks. We report a rare case of the migration of a previously impacted bullet in the liver into the CBD, causing acute severe biliary obstruction and our innovative approach in retrieving it.

Case Description/Methods: A 42-year-old male with a history of a gunshot wound to the abdomen and retained bullet in the liver a year ago was admitted to an outside facility for increasing upper abdominal pain. He was diagnosed with cholecystitis a month ago and underwent cholecystectomy. Three days later, he experienced worsening abdominal pain and jaundice and was transferred to our facility.

On evaluation, the patient had normal vital signs and was jaundiced with significant right upper quadrant abdominal tenderness. The initial lab tests showed WBC 11.5 thousand cells/mm³, Hb 11.1 gm/dL, AST 126 U/L, ALT 219 U/L, Alkaline phosphatase 817 U/L and total bilirubin of 40.5 mg/dL (direct bilirubin of 38). A CT scan of the abdomen revealed common bile duct (CBD) dilatation to 2 cm and a retained bullet in the duct, along with moderate intrahepatic ductal dilation (Figure A and B). An emergent ERCP showed a dilated CBD to 2 cm. Attempts at removing the impacted bullet but were unsuccessful. The bullet was proximally pushed with a stone extraction balloon. A sphincterotomy was performed, and a self-expandable metal stent was placed. The patient had some improvement in his symptoms and bilirubin. A repeat ERCP performed after two days revealed the impacted bullet at the distal CBD. The stent was removed, sphincterotomy was extended with a needle knife and the impacted bullet was then successfully retrieved with a rat-tooth forceps (Figure C). This resulted in further symptom relief and a dramatic fall in the liver tests.

Discussion: Impacted bullet in the CBD is extremely rare. It is also interesting in our patient that the distal ductal migration of this bullet was seen nearly a year after the initial gunshot injury. To date, only four cases have been reported; two of these cases were noted after choledocho-jejunal anastomosis. Only in one of these cases was a non-surgical approach used to relieve the obstruction. In addition, our case, with impacted bullet at the distal CBD one year after the injury is the first to be reported in a patient with severe jaundice (bilirubin 40 mg/dL). Our approach of sphincterotomy and initial metal stent placement helped removal of the distally migrated and impacted bullet in the distal CBD.



Disclosures:


Amit Hudgi, MD¹, Dariush Shahsavari, MD², Kuldeep Kaur. Randhawa, MBBS³, Sarabjeet Kaur, MBBS¹, Spencer Fields, MS¹, Brandon Garten, BS¹, Suraj S. Padakanti, MBBS¹, Subbaramiah Sridhar, MBBS, MPH². P0093 - Bullets Don’t Always Travel Straight - Journey of a Lodged Bullet into the Common Bile Duct, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.