S2372 Bullets Don’t Always Travel Straight - Journey of a Lodged Bullet into the Common Bile Duct

Introduction: Traumatic injuries to the biliary tract are uncommon and usually lead to bile leaks. We report a rare case of the migration of a previously impacted bullet in the liver into the common bile duct (CBD), causing acute severe biliary obstruction and our innovative approach in retrieving it. Case Description/Methods: A 42-year-old man with a history of a gunshot wound to the abdomen and retained bullet in the liver a year ago was admitted to an outside facility for increasing upper abdominal pain. He was diagnosed with cholecystitis a month ago and underwent cholecystectomy. Three days later, he experienced worsening abdominal pain and jaundice and was transferred to our facility. On evaluation, the patient had normal vital signs and was jaundiced with significant right upper quadrant abdominal tenderness. The initial lab tests showed white blood cells 11.5 thousand cells/mm³, Hb 11.1 gm/dL, aspartate aminotransferase 126 U/L, alanine transaminase 219 U/L, alkaline phosphatase 817 U/L and total bilirubin of 40.5 mg/dL (direct bilirubin of 38). A CT scan of the abdomen revealed CBD dilatation to 2 cm and a retained bullet in the duct, along with moderate intrahepatic ductal dilation (Figure 1A and B). An emergent endoscopic retrograde cholangiopancreatography (ERCP) showed a dilated CBD to 2 cm. Attempts at removing the impacted bullet but were unsuccessful. The bullet was proximally pushed with a stone extraction balloon. A sphincterotomy was performed, and a self-expandable metal stent was placed. The patient had some improvement in his symptoms and bilirubin. A repeat ERCP performed after 2 days revealed the impacted bullet at the distal CBD. The stent was removed, sphincterotomy was extended with a needle knife and the impacted bullet was then successfully retrieved with a rat-tooth forceps (Figure 1C). This resulted in further symptom relief and a dramatic fall in the liver tests. Discussion: Impacted bullet in the CBD is extremely rare. It is also interesting in our patient that the distal ductal migration of this bullet was seen nearly a year after the initial gunshot injury. To date, only 4 cases have been reported; 2 of these cases were noted after choledocho-jejunal anastomosis. Only in one of these cases was a non-surgical approach used to relieve the obstruction. In addition, our case, with impacted bullet at the distal CBD one year after the injury is the first to be reported in a patient with severe jaundice (bilirubin 40 mg/dL). Our approach of sphincterotomy and initial metal stent placement helped removal of the distally migrated and impacted bullet in the distal CBD.Figure 1.: A,B) Computed tomography abdomen showing retained bullet in the common hepatic duct with subsequent ductal dilation. Figure C: Endoscopic retrograde cholangiopancreatography with retrieval of bullet using rat tooth forceps.

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