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Cholangitis as a result of hydrophilic guidewire fracture
BRIEF REPORTS Cholangitis as a result of hydrophilic guidewire fracture Lucía C. Fry, MD, Jeffrey D. Linder, MD, Klaus E. Mönkemüller, MD
Numerous guidewires are now available, ranging from standard to hydrophilic and Zebra (Microvasive Endoscopy, Natick, Mass.) to pathfinder (Microvasive Endoscopy, Natick, Mass.).1-4 Hydrophilic guidewires, a major addition to the therapeutic armamentarium, are being used increasingly during ERCP. Some of the most popular combine a rigid shaft with a floppy tip that is coated with a hydropolymer, which causes the guidewire to become exceedingly slippery on contact with water.1 This property makes these guidewires extremely useful in difficult cases for facilitation of bile duct cannulation and traversing benign and malignant strictures of the biliary and pancreatic ducts.2 The rigid, nonkinking portion of the shaft makes it possible to maintain proper position during sphincterotomy, cross strictures, and when exchanging various catheters and other accessories as well as allowing direct insertion of 7F stents. However, there are several reports of guidewire fracture in which the floppy tip became detached from the shaft.2-5 In no reported case was the guidewire fracture followed by a significant immediate or longterm pancreaticobiliary complication.2-4 However, reported here is a case of cholangitis as a consequence of hydrophilic guidewire fracture. CASE REPORT A 61-year-old man underwent ERCP for cholestasis and bile duct dilation by CT. The procedure was performed by using a therapeutic duodenoscope (TJF-160, Olympus America, Melville, N.Y.). Deep cannulation of the bile duct could not be achieved with a standard biliary catheter or sphincterotome. Therefore a hydrophilic guidewire (Jagwire, Microvasive Endoscopy, Natick, Mass.) was used. The guidewire was new and never used previously. Deep bile duct cannulation was accomplished after several minutes of manipulation of the papillary orifice with guidewire and sphincterotome. The tip of the guidewire was advanced a slight distance beyond the tip of the sphincterotome and into the papilla. A short common channel was present and Current affiliations: Division of Gastroenterology, VA Medical Center, University of Alabama, Birmingham, Alabama. Reprint requests: Klaus E. Mönkemüller, MD, Division of Gastroenterology, University of Alabama, 633 ZRB, UAB Station Birmingham, AL 35294. 37/54/129877 doi:10.1067/mge.2002.129877 VOLUME 56, NO. 6, 2002
Figure 1. X-ray film showing fractured floppy end of guidewire in distal bile duct.
Figure 2. Fractured floppy end of hydrophilic guidewire. (Insert, detached floppy tip). Fracture of the inner monofilament core occurred at the junction of the floppy tip and main (i.e., stiff) shaft; the hydropolymer coating on the floppy tip is intact. the guidewire preferentially entered the pancreatic duct. While in the common channel, the guidewire was moved back-and-forth and clockwise torque was applied until deep cannulation of the bile duct was achieved. Both intrahepatic systems were also selectively cannulated with the aid of the guidewire. Cholangiography was normal; the bile duct diameter was 5 mm. A postprocedure radiograph was not obtained. The patient was discharged after the procedure but returned 1 day later complaining of abdominal pain, fever, chills, and jaundice. Examination revealed tenderness to palpation in the epigastrium and right upper quadrant. Laboratory data were as follows: white blood cell count, 19,000/mL (normal: 4500-11,000/mL) with 92% neutrophils; alkaline phosphatase, 300 IU/L (normal: 38-126 IU/L); total bilirubin, 5.1 mg/dL (0.2-1.3 mg/dL). Treatment was initiated with intravenous administration of antibiotics with broad antimicrobial coverage (piperacillin/tazobactam), and ERCP was performed on an emergent basis. A fragment of the guidewire was visualized in the bile duct (Fig. 1). After sphincterotomy the fragment and pus were removed with a 15-mm extraction balloon and a snare. Close inspection revealed that the entire floppy end of the guidewire had separated from the stiff component (Fig. 2). The cholangitis resolved rapidly and the patient was discharged 3 days later. GASTROINTESTINAL ENDOSCOPY
943
F Plath, P Brock, N Hasse, et al.
DISCUSSION This is the first report of a significant post-ERCP complication associated with fracture of a hydrophilic guidewire. The reason for the fracture is unknown, but most likely it resulted from rotational forces secondary to torquing maneuvers during placement in the common bile and intrahepatic ducts. Other proposed mechanisms for guidewire fracture during ERCP include excessive traction2,4 and an electrical short circuit between the cutting wire of a sphincterotome and the guidewire.3,6 Excessive traction and shearing forces can result from pulling a guidewire with a “knotted” floppy tip through the biliary catheter.2,7 If “unknotting” does not occur it is advisable to pull out the guidewire together with the catheter and manually unknot the guidewire, or preferably discard it and use a new one. Previous reports mention theoretical risks of leaving guidewire fragments in the pancreatic and biliary ducts including infection, abscess due to foreign body reaction, and impedance of normal drainage, but these potential complications have not been substantiated by published information.2,4 It is possible that such complications have occurred but have not been reported. Nevertheless, the present report documents a significant risk for the development of cholangitis due to the presence of a fractured guidewire tip within the biliary tract. Also, it is believed that manipulation of the papilla with resultant edema around the orifice transiently
944
GASTROINTESTINAL ENDOSCOPY
Brief Reports
impeded proper bile flow and that bacterial contamination during ERCP both contributed to the development of cholangitis. Therefore, to prevent this complication, guidewires should be inspected after each ERCP, especially if significant manipulation of the guidewire occurred during the procedure. Also, a postprocedure x-ray film should be obtained in every case where guidewire cannulation was used, not only to evaluate for occult perforation, but also to rule out the presence of a guidewire fragment. If a fragment has been accidentally left in the biliary tract, an attempt should be made to remove it. REFERENCES 1. ASGE. Technology assessment status evaluation: guidewires in gastrointestinal endoscopy. American Society for Gastrointestinal Endoscopy. Gastrointest Endosc 1998;47:579-83. 2. Pruitt A, Schutz SM, Baron TH, Mc Clendon D, Lang KA. Fractured hydrophilic guidewire during ERCP: a case series. Gastrointest Endosc 1998;48:77-80. 3. Burdick JS, Schmalz MJ, Greenen JE. Guidewire fracture during endoscopic sphincterotomy. Endoscopy 1993;25:251-2. 4. Heinerman M, Mann R, Boeckl O. An unusual complication in attempted non-surgical treatment of pancreatic bile duct stones. Endoscopy 1993;25:248-50. 5. Keltai M, Bartek I, Biro V. Guidewire snap causing left main occlusion during coronary angioplasty. Cath Cardiovasc Diagnostics 1986;12:324-6. 6. Johlin FC, Tucker RD, Ferguson S. The effect of guidewires during electrosurgical sphincterotomy. Gastrointest Endosc 1992;38:536-40. 7. Bhasin DK, Poddar U, Wig JD. Knot formation in a floppytipped guidewire in the common bile duct: an unusual complication of ERCP. Endoscopy 2000;32:517.
VOLUME 56, NO. 6, 2002
Numerous guidewires are now available, ranging from standard to hydrophilic and Zebra (Microvasive Endoscopy, Natick, Mass.) to pathfinder (Microvasive Endoscopy, Natick, Mass.).1-4 Hydrophilic guidewires, a major addition to the therapeutic armamentarium, are being used increasingly during ERCP. Some of the most popular combine a rigid shaft with a floppy tip that is coated with a hydropolymer, which causes the guidewire to become exceedingly slippery on contact with water.1 This property makes these guidewires extremely useful in difficult cases for facilitation of bile duct cannulation and traversing benign and malignant strictures of the biliary and pancreatic ducts.2 The rigid, nonkinking portion of the shaft makes it possible to maintain proper position during sphincterotomy, cross strictures, and when exchanging various catheters and other accessories as well as allowing direct insertion of 7F stents. However, there are several reports of guidewire fracture in which the floppy tip became detached from the shaft.2-5 In no reported case was the guidewire fracture followed by a significant immediate or longterm pancreaticobiliary complication.2-4 However, reported here is a case of cholangitis as a consequence of hydrophilic guidewire fracture. CASE REPORT A 61-year-old man underwent ERCP for cholestasis and bile duct dilation by CT. The procedure was performed by using a therapeutic duodenoscope (TJF-160, Olympus America, Melville, N.Y.). Deep cannulation of the bile duct could not be achieved with a standard biliary catheter or sphincterotome. Therefore a hydrophilic guidewire (Jagwire, Microvasive Endoscopy, Natick, Mass.) was used. The guidewire was new and never used previously. Deep bile duct cannulation was accomplished after several minutes of manipulation of the papillary orifice with guidewire and sphincterotome. The tip of the guidewire was advanced a slight distance beyond the tip of the sphincterotome and into the papilla. A short common channel was present and Current affiliations: Division of Gastroenterology, VA Medical Center, University of Alabama, Birmingham, Alabama. Reprint requests: Klaus E. Mönkemüller, MD, Division of Gastroenterology, University of Alabama, 633 ZRB, UAB Station Birmingham, AL 35294. 37/54/129877 doi:10.1067/mge.2002.129877 VOLUME 56, NO. 6, 2002
Figure 1. X-ray film showing fractured floppy end of guidewire in distal bile duct.
Figure 2. Fractured floppy end of hydrophilic guidewire. (Insert, detached floppy tip). Fracture of the inner monofilament core occurred at the junction of the floppy tip and main (i.e., stiff) shaft; the hydropolymer coating on the floppy tip is intact. the guidewire preferentially entered the pancreatic duct. While in the common channel, the guidewire was moved back-and-forth and clockwise torque was applied until deep cannulation of the bile duct was achieved. Both intrahepatic systems were also selectively cannulated with the aid of the guidewire. Cholangiography was normal; the bile duct diameter was 5 mm. A postprocedure radiograph was not obtained. The patient was discharged after the procedure but returned 1 day later complaining of abdominal pain, fever, chills, and jaundice. Examination revealed tenderness to palpation in the epigastrium and right upper quadrant. Laboratory data were as follows: white blood cell count, 19,000/mL (normal: 4500-11,000/mL) with 92% neutrophils; alkaline phosphatase, 300 IU/L (normal: 38-126 IU/L); total bilirubin, 5.1 mg/dL (0.2-1.3 mg/dL). Treatment was initiated with intravenous administration of antibiotics with broad antimicrobial coverage (piperacillin/tazobactam), and ERCP was performed on an emergent basis. A fragment of the guidewire was visualized in the bile duct (Fig. 1). After sphincterotomy the fragment and pus were removed with a 15-mm extraction balloon and a snare. Close inspection revealed that the entire floppy end of the guidewire had separated from the stiff component (Fig. 2). The cholangitis resolved rapidly and the patient was discharged 3 days later. GASTROINTESTINAL ENDOSCOPY
943
F Plath, P Brock, N Hasse, et al.
DISCUSSION This is the first report of a significant post-ERCP complication associated with fracture of a hydrophilic guidewire. The reason for the fracture is unknown, but most likely it resulted from rotational forces secondary to torquing maneuvers during placement in the common bile and intrahepatic ducts. Other proposed mechanisms for guidewire fracture during ERCP include excessive traction2,4 and an electrical short circuit between the cutting wire of a sphincterotome and the guidewire.3,6 Excessive traction and shearing forces can result from pulling a guidewire with a “knotted” floppy tip through the biliary catheter.2,7 If “unknotting” does not occur it is advisable to pull out the guidewire together with the catheter and manually unknot the guidewire, or preferably discard it and use a new one. Previous reports mention theoretical risks of leaving guidewire fragments in the pancreatic and biliary ducts including infection, abscess due to foreign body reaction, and impedance of normal drainage, but these potential complications have not been substantiated by published information.2,4 It is possible that such complications have occurred but have not been reported. Nevertheless, the present report documents a significant risk for the development of cholangitis due to the presence of a fractured guidewire tip within the biliary tract. Also, it is believed that manipulation of the papilla with resultant edema around the orifice transiently
944
GASTROINTESTINAL ENDOSCOPY
Brief Reports
impeded proper bile flow and that bacterial contamination during ERCP both contributed to the development of cholangitis. Therefore, to prevent this complication, guidewires should be inspected after each ERCP, especially if significant manipulation of the guidewire occurred during the procedure. Also, a postprocedure x-ray film should be obtained in every case where guidewire cannulation was used, not only to evaluate for occult perforation, but also to rule out the presence of a guidewire fragment. If a fragment has been accidentally left in the biliary tract, an attempt should be made to remove it. REFERENCES 1. ASGE. Technology assessment status evaluation: guidewires in gastrointestinal endoscopy. American Society for Gastrointestinal Endoscopy. Gastrointest Endosc 1998;47:579-83. 2. Pruitt A, Schutz SM, Baron TH, Mc Clendon D, Lang KA. Fractured hydrophilic guidewire during ERCP: a case series. Gastrointest Endosc 1998;48:77-80. 3. Burdick JS, Schmalz MJ, Greenen JE. Guidewire fracture during endoscopic sphincterotomy. Endoscopy 1993;25:251-2. 4. Heinerman M, Mann R, Boeckl O. An unusual complication in attempted non-surgical treatment of pancreatic bile duct stones. Endoscopy 1993;25:248-50. 5. Keltai M, Bartek I, Biro V. Guidewire snap causing left main occlusion during coronary angioplasty. Cath Cardiovasc Diagnostics 1986;12:324-6. 6. Johlin FC, Tucker RD, Ferguson S. The effect of guidewires during electrosurgical sphincterotomy. Gastrointest Endosc 1992;38:536-40. 7. Bhasin DK, Poddar U, Wig JD. Knot formation in a floppytipped guidewire in the common bile duct: an unusual complication of ERCP. Endoscopy 2000;32:517.
VOLUME 56, NO. 6, 2002