Suspected blockage of metallic stent in a patient with cholangiocarcinoma

This 65 year old patient had two metallic stents placed over the past 18 months. The first was an uncovered stent, followed 8 months later by a partially covered stent placed within the first one. He had now presented with raised bilirubin. The ultrasound scan showed multiple hepatic lesions with query between abscesses and metastatic lesions. The stent seemed patent on direct viewing (A: green arrow). A guidewire was maneuvered across the stent (B: green arrows marking the guidewire and red arrows show the previously placed metallic stent) followed by contrast injection which outlined a patent stent and normal calibre intrahepatic biliary channels (C1 & C2: green arrows). We flushed the stents with saline which removed some debris (D: green arrows show the patent stent and full washout of contrast). Our conclusion was that the raised bilirubin, coupled with patent stents and normal calibre intrahepatic biliary ducts, was attributable to the liver metastatic lesions.