Biliary stricture and fistula

This lady had a cholecystectomy done a year ago. She had been having recurrent cholangitis since then. The latest ultrasound reported a distal biliary stricture and calculi in the proximal CBD. The CA 19-9 was 494 IU. Things got interesting when we got in. There was no bile output from the ampulla. The duodenal bulb had a lot of bile (A). The source was a fistulous biliary opening at the junction of the bulb and descending duodenum which we tried to cannulate (an attempt at CBD cannulation in this patient had been unsuccessful last week) but were unsuccessful (B). A reattempt at CBD cannulation via the papilla was successful (C). The cholangiogram showed cutoff of contrast at the upper end of CBD with the fistulous tract outlined and draining into the duodenum (D: green arrows showing the thin fistula tract. The inadequate diameter of the tract explained her recurrent cholangitis episodes). We got the guidewire through the stricture (E) followed by dilatation of the stricture with a Soehendra stent retriever (F). The subsequent cholangiogram showed dilated upper channels and the fistula tract again (G: green arrows show the stent, red arrows marking the fistula tract). We passed a 10F x 12cm plastic stent. She was advised to have a biphasic CT abdomen and review by the hepatobiliary surgeon.