Incluido en la revista Ocronos. Vol. IX. N.º 2–Febrero 2026. Pág. Inicial: Vol. IX; N.º 2: 55
Autor principal (primer firmante): Joab Abner Lerma Herrera
Fecha recepción: 23/01/2026
Fecha aceptación: 04/02/2026
Ref.: Ocronos. 2026;9(2): 55
https://doi.org/10.58842/CGZA1094
Authors:
Joab A. Lerma Herrera (1), Diana L. Gómez Pérez (1), Paola E. López Gálvez (1), Osvaldo Báez Camacho (1).
1 Universidad Autónoma de Sinaloa, Hospital Regional Manuel Cárdenas de la Vega, Department of Internal Medicine (1).
*Corresponding author:
Dr. Joab A. Lerma Herrera
Department of Internal Medicine
Universidad Autónoma de Sinaloa
Culiacán, Sinaloa, Mexico
Introduction
Placement of a biliary stent through Endoscopic Retrograde Cholangiopancreatography (ERCP) is a relatively common procedure performed to relieve biliary obstruction, which causes or increases the risk of cholangitis. Depending on the type of stent used, it generally remains in the biliary tract for a period of at least six months. However, in a significant percentage of cases, the stent may migrate through the small intestine and subsequently into the colon until it is expelled. Despite this, there is limited literature on intestinal perforation secondary to biliary stent migration. Recognizing prior biliary stent placement is therefore important when evaluating patients presenting with abdominal pain, as stent-related intestinal perforation should be considered in the differential diagnosis.
Case presentation
A 64-year-old male, with no family history of cancer, was diagnosed with pancreatic head adenocarcinoma confirmed by biopsy following an ERCP performed in April 2025. He received chemoradiotherapy with gemcitabine and capecitabine. Later, he developed complications related to dysfunction of the initially placed biliary stent, presenting with progressive jaundice, abdominal pain, and fever of 39°C, meeting both clinical and laboratory criteria based on the Tokyo Guidelines for acute cholangitis. A second ERCP was required in May 2025.
Case report- when the unexpected occurs- sigmoid colon perforation after biliary stent placement.pdf
Images 1 and 2 show axial computed tomography slices demonstrating a hyperdense artifact in the sigmoid colon corresponding to a biliary stent. Image 2 also shows the stent perforating the colon without evidence of free intra-abdominal air.
In July 2025, the patient developed abdominal pain compatible with an acute abdomen. Abdominopelvic CT revealed findings suggestive of intestinal perforation at the level of the sigmoid colon secondary to the previously placed biliary stent (Images 1 and 2). Exploratory laparotomy was performed, revealing a perforation located within a diverticulum of the sigmoid colon. A segmental sigmoidectomy and end colostomy were carried out.
On July 31, the patient developed urinary incontinence, mood changes, amnesia, disorientation, and fever without a circadian pattern. Laboratory tests revealed the abnormalities shown in Table 1 and 2.
Table 1. Serum Chemistry Results.
Table 2. Blood count findings.
Case report- when the unexpected occurs- sigmoid colon perforation after biliary stent placement.pdf
Antibiotic therapy was initiated with ceftriaxone and metronidazole, later escalated to carbapenems due to lack of clinical improvement and the presence of criteria for severe acute cholangitis, according to the Tokyo Guidelines. The biliary stent was determined to be dysfunctional, so percutaneous biliary drainage was performed, resulting in improvement of cholestatic parameters and control of the abdominal septic process. After several weeks of supportive management based on intravenous fluids and enteral/parenteral nutrition, the patient was discharged to his medical unit and later home with a colostomy (Images 3 and 4).
Case report- when the unexpected occurs- sigmoid colon perforation after biliary stent placement.pdf
Images 3 and 4. Sagittal and coronal CT slices demonstrating postoperative changes following hemicolectomy and colostomy.
Discussion
The use of biliary stents for biliary drainage has increased and has shown excellent outcomes, becoming the treatment of choice in many cases. However, with increased use, complications have also become more evident. Migration of biliary stents can occur in 5–10% of patients(1), and although stent migration is relatively common (up to 14% in plastic stents), only approximately 1% of cases result in intestinal perforation, as the vast majority of migrated stents pass spontaneously in the stool(2).
This case illustrates the complexity of managing severe acute cholangitis in patients with pancreatic malignancy and complications secondary to stent dysfunction, migration, and even perforation. Current guidelines emphasize the importance of timely biliary drainage—endoscopic or percutaneous—and appropriate broad-spectrum antibiotics adjusted according to clinical response.
Although rare, colonic perforation secondary to biliary stent migration may lead to serious complications, including peritonitis.(3) Diverticular disease increases the risk of perforation, with the sigmoid colon being the most commonly affected site.(4)
Stent dysfunction is believed to result from duodenobiliary reflux—retrograde flow of duodenal content into the biliary system—secondary to endoscopic sphincterotomy, which disrupts the sphincter of Oddi. This leads to increased viscosity of bile and promotes bacterial colonization, commonly Escherichia coli, Klebsiella spp., Enterococcus spp., and Streptococcus spp. Over time, biofilm formation increases the risk of obstruction and acute cholangitis. Routine stent replacement is therefore recommended(5). However, repeat ERCP procedures also carry risks, including post-ERCP pancreatitis, and increasing the number of interventions elevates the cumulative risk of complications. This patient required two ERCP procedures within a short interval, which may have contributed to the course of events.
Tokyo Guidelines 2018 – Diagnostic criteria for acute cholangitis.
Suspected diagnosis:
Requires: 1 criterion from Category A + 1 criterion from Category B or C.
Definitive diagnosis:
Requires: 1 criterion from Category A + 1 criterion from Category B + 1 criterion from Category C.
Case report- when the unexpected occurs- sigmoid colon perforation after biliary stent placement.pdf
Conclusion
Severe acute cholangitis in the setting of biliary stent dysfunction and complications such as intestinal perforation represents a significant diagnostic and therapeutic challenge. Percutaneous biliary drainage combined with targeted antimicrobial therapy remains a cornerstone of management, improving clinical outcomes in complex cases such as the one described. However, the lack of standardized protocols to reduce biliary stent migration continues to present difficulties, underscoring the need for improved preventive strategies.
Declarations
- Conflict of interest: None of the authors report conflicts of interest.
- Ethical approval: This case report involves an anonymous patient and all treatment adhered to international guidelines.
Keywords:
Perforation, Colon, Biliary Stent, Cholangitis, Endoscopic Retrograde Cholangiopancreatography, Surgery.
Case report- when the unexpected occurs- sigmoid colon perforation after biliary stent placement.pdf
References
- Beloy JB, Lund NP, Van Hell AM, Allamaneni S. Case report: Migratory biliary stent resulting in sigmoid colon perforation. J Surg Case Rep [Internet]. 2024;2024(11):rjae737. Available from: http://dx.doi.org/10.1093/jscr/
- Jadallah K, Alzubi B, Sweidan A, Almanasra AR. Intraperitoneal duodenal perforation secondary to early migration of biliary stent: closure with through-the-scope clip. BMJ Case Rep [Internet]. 2019;12(9):e230324. Disponible en: http://dx.doi.org/10.1136/bcr-2019-230324
- Asghari Y, Firuzpour F. Distal sigmoid perforation secondary to migration of a biliary stent: A case report. Int J Surg Case Rep [Internet]. 2025;128(110921):110921. Available from: http://dx.doi.org/10.1016/j.ijscr.2025.110921
- Beloy JB, Lund NP, Van Hell AM, Allamaneni S. Case report: Migratory biliary stent resulting in sigmoid colon perforation. J Surg Case Rep [Internet]. 2024;2024(11):rjae737. Available from: http://dx.doi.org/10.1093/jscr/
- Yusoff AR, Kamarul Anuar QZD, Khalid S, Mokhtar S. Acute cholangitis secondary to a clogged biliary Stent: A review on the cause of clogging and the appropriate time of replacement. Case Rep Gastroenterol [Internet]. 2022;16(1):55–61. Available from: http://dx.doi.org/10.1159/000521942