Unusual case of dp-10 tip as a precursor for adult duodenal intussusception. Abbreviations we used are dpt for dp, cct for contrast enhanced computed tomography, eus for endoscopic ultrasound, chd for common hepatic duct, cbd for common bowel duct. We have none to disclose as far as the funding and the relationship with the industry are concerned. In the background, duodenal-duodenal intussusceptions in adult age group are uncommon. They may account for only 5% of all cases. In adults, there is usually a benign lesion acting as a late point in all reported cases in literature so far. CCT abdomen followed by EUS and sometimes endoscopic evaluation are the key modalities for the diagnosis. We present a case of 60-year-old female who has presented to us with a history of abdominal pain over right hypochondrium since 20 days, past history of polycystectomy 3 years back, past history of ARCP twice in a year, 1 month apart. No reports were available for the review. On examination, there was no itch truss, her abdominal examination was soft, non-tender and there was no guarding or rigidity. Her ultrasound abdomen was suggestive of CHD and suprapancreatic CBD dilated up to 20 mm. It was anechoic with a CBD stent in situ. CCT abdomen was suggestive of motor dilatation of IHBR and common bell duct. Biochemical investigations such as CBC and LFTs were within normal limits. We can see that there is a double pigtail stent with a duodenal intussusception. What we are trying to do is try to dislodge the stent with whatever accessories we had. We first tried to pull the stent with a rat tooth forceps, then we took a stiff cannula and we tried to reduce the intussusception over the stent by pushing it down. But both these manoeuvres failed. We did not know what to do. Therefore we thought of changing the scope at this juncture and we removed the side wing scope and planned to put in a forward wing scope. The intussusception as you can see is so stiff and so rigid that we could not dislodge it. We even tried to separate the mucosa. This is the end wing scope. With a rat tooth forceps we are trying to push the intussusception, trying to pull the stent again but all these manoeuvres failed. So we applied a little traction on the stent, pulled it a little back and then pushed the end wing gastro scope along the stent into the intussusception and tried to make our way to finding the tip. Once we pushed, we could reduce the intussusception and we could see the stent embedded in the duodenal mucosa. Then we took a snare, caught hold of the end of the double pigtail stent and pulled the stent out through the channel of the scope. Therefore we could reduce the intussusception. After this we reintroduced the side wing scope, swept the bile duct, cleared the bile duct of all the sludge that it was because the stent was in for a long time and we could identify the hole, the perforation which the stent had caused and there was very little air which we could appreciate on fluoroscopy and therefore we decided to close this rent and we used a haemoclip to close the small perforation which the stent tip had caused. Once we closed this perforation, the patient was kept nilorally for a few hours, her abdominal conditions were examined and once everything was settled, she was started on oral liquids. In post-operative course and follow-up, the patient was admitted for 24 hours. She was given intravenous antibiotics. There were no complications during the observation period and she was discharged the next day. On follow-up at one month, she was absolutely asymptomatic. To conclude with, this is an unusual case wherein an impacted tip of a double-pictile stent caused an ADUD intussusception and was treated endoscopically. Biliary stents can cause unforeseen complications and we should be observant and vary during stent removal in all cases.

adult duodenal intussusception

impacted double-pigtail stent

abdominal pain

endoscopic stent removal

haemoclip closure