Stent migration has been described either sporadically in

Stent BTL-104 has been described either sporadically in case reports or as an uncommon complication in larger series. Johanson et al followed 322 biliary stent placements and found 19 cases (5.9%) of distal stent migration. Another series of 297 stent placements demonstrated 11 cases (3.7%) of distal migration. Mueller et al reported six episodes of distal stent migration in a series of 102 stentings, giving rise to an incidence of 5.8%. Taken together, the distal migration rate after stent placement is around 5%. Most distally migrated stents pass off spontaneously. The most common site of a dislodged biliary stent is the duodenum, whereas impaction in other portions of small bowel or colon is rare. A variety of injuries have been reported from stent migration, with bowel perforation being the most commonly reported one that tends to occur in patients with diverticular disease, hernia, or intra-abdominal adhesion. None of the above conditions was applicable to our patient who suffered from colonic erosion and hemorrhage from a dislodged biliary stent leading to the impression of recurrent hemobilia. Namdar et al have reviewed a series of 11 cases of colon perforation from biliary stent impaction, all of which occurred in the sigmoid colon. Although the sigmoid colon seems to be the most common site of stent-related colon perforation, sporadic cases of colon perforation at other sites of the colon have also been reported. Berry et al have described a case of stent migration from the common bile duct to the transverse colon through chronic erosion and fistula formation, giving rise to late colonic hemorrhage. Moreover, colon perforation with abscess formation around the ascending colon has also been reported in a patient with a missing stent 2 months after an unsuccessful endoscopic biliary stenting. Our present case is unique in that colonic hemorrhage occurred from a dislodged stent impacted in the ascending colon after a previous episode of hemobilia. Diller et al suggested prompt intervention and stent removal for symptomatic patients after successful surgical treatment of five cases of distal biliary stent migration. In the case of our patient, prompt endoscopic removal of the impacted stent not only attained hemostasis successfully under unstable condition despite aggressive resuscitation, but also prevented further complications such as perforation and fistula formation. Therefore, our case also strengthens this proposal further. Hemostasis after the procedure was possibly due to the removal of the embedded tip of the stent that not only caused erosion with active bleeding on the colonic mucosa, but also hampered the physiological peristalsis of the colon. Hemorrhage from the lesion may be stopped by unimpeded colonic contraction after foreign body removal.
Introduction Spontaneous intestinal perforation is a rare complication, occuring in 1–15% among patients with tuberculous (TB) enteritis. Much rarer, are TB intestinal perforations among patients receiving anti-TB treatment. This is the so-called paradoxical response phenomenon, e.g., the occurrence of clinical or radiological worsening of pre-existing TB lesions, or the development of new lesions not attributable to the normal course of the disease in a patient who initially improves from the anti-TB treatment. This may occur once, but recurrent perforations in a single patient is very rare; only a few case reports have so far been published in the English literature describing such perforations.
Case report A 52-year-old male painter was admitted for the first time on January 25, 2011 because of a sudden severe abdominal pain of 1-day duration. Two to three months prior to e admission, he had begun to have severe cough persisting until 1 month prior to the admission when he had a pulmonary consult. A chest X-ray at that time revealed severe lung infiltration with possible abscess formation (Fig. 1A). Culture was positive for mycobacterium. He was started on a four-drug anti-TB regimen (Rifater 5 tabs QD and EMB 2 tabs QD) 20 days prior to admission. Eleven days prior to admission, he had a vague abdominal discomfort and was treated conservatively for an assumed consequence of anti-TB drugs. One day prior to admission, he had severe abdominal pain with inability to take food and, later, manifestations of peritonitis. Laboratory data revealed hemoglobin of 14.4 g and white blood cell (WBC) of 7700 (77% segmented). Renal and liver functions were normal. Abdominal computed tomography (CT) revealed minimal pneumoperitoneum around intestinal walls, and ascites. Emergency laparotomy was done revealing a 0.3 cm perforation with surrounding induration at the mid-jejunum about 3 ft distal to the ligament of Treitz. Suppurative ascites amounting to 500 cc with exudative coating of intestines was noted. Several nodular indurations of the small intestines, interspersed with normal appearing segments, were also seen throughout the whole length of the small bowels. The large intestine, peritoneal surface, and livers were grossly uninvolved. Segmental resection of 1.5 ft of jejunum containing the perforation was done with end-to-end anastomosis. Postoperative recovery was smooth. He was discharged 1 week later with resumption of anti-TB drugs. Pathology of the resected specimen revealed several granulomas with abundant acid-fast bacilli. Fifty one days after the first operation, another episode of peritonitis was noted. Leucocytosis was found to be 18,920 (90% segmented). He received surgical intervention at another hospital. Operation revealed a 1.0 cm perforation in the terminal ileum, and segmental resection with primary anastomosis was done. Pathologic report of the resected specimen revealed neither granuloma nor TB organism. He was discharged after 10 days of hospital stay. Seventy-five days after the second operation, he had another bout of peritonitis. CT scan revealed frank pneumoperitoneum and a WBC count of 16,220 (85% segmented), and he underwent his third operation. Operative findings consisted of a 0.5 cm perforation at the junction of the terminal ileum and cecum; several flimsy adhesions were noted between the small intestine, pelvis, and peritoneal wall. The entire small intestinal bowel wall was markedly thickened, and purulent ascites of about 300 cc with fecal peritonitis was also noted. Skip lesions were not discernible anymore. Right hemicolectomy was done, including the visible previous anastomosis in the terminal ileum during the second operation, extending to the proximal transverse colon. Postoperative recovery was uneventful, and he was discharged 10 days later. Pathology of the resected specimen revealed thickening of the bowel wall, with a localized thinned out perforation area at the ileocecal junction. No sign of intestinal obstruction was visible. The resected specimen revealed no granuloma or acid-fast bacilli.