This gentleman had undergone a living donor liver transplant approximately a month ago. A plastic biliary stent had been placed for an anastomotic stricture about three weeks after transplant. This was eight days ago. His total bilirubin level dropped from 15 mg/dL to 10.5 mg/dL in the 72 hours following stent placement. He then experienced fever along with rising bilirubin levels. We expected that the stent was blocked ( we had noted a significant amount of sludge along with bile flowing from the stent the first time we had placed it). Sure enough, we were met with a choked stent on ERCP (A1). We grabbed it with a snare (A2 & A3) and removed it (A4). We then generously flushed the bile duct with saline to wash out all debris (B1). A small papillotomy was also done to assist in drainage of the sludge (B2). Repeat contrast injection was done to check the status of the stricture. Sure enough, the stricture was present just behind the endoscope (C: white arrow). Since it had been only four weeks since the transplant, we avoided balloon dilatation of the strictured area (We had already "stretched" protocol by placing stent larger than 7 French diameter just three weeks after transplant in this patient. We had placed a 10 French stent and vendors that had been blocked). A similar 10 French plastic stent of 10 cm length was placed (D1 & D2: white arrows). A gush of bile and sludge was seen (E). We're keeping our fingers crossed as there is a probability that this stent might become blocked as well over the next one to two weeks.
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