Hydrostatic reduction of iatrogenic duodenal intussusception during biliary drain exchange: A case report

Intussusception of the duodenum caused by internal/external biliary drain exchange is extremely rare but potentially life-threatening. If unrecognized, it may rapidly progress to bowel ischemia, necrosis and perforation, and thus is an important complication to recognize and treat immediately. We present the case of a 62 years old man with unresectable duodenal adenocarcinoma involving the common bile duct, managed with palliative internal/external biliary drain. During routine exchange under fluoroscopy, a duodenal intussusception was identified when contrast injection revealed a filling defect in the third part of the duodenum. The presumed mechanism was traction on the inner mucosa during retraction of the catheter. Prompt reduction of the intussusception was safely and successfully performed by rapidly injecting saline and contrast into the duodenum, avoiding complications. The patient recovered well and was discharged later that day. This case highlights a rare but important complication of biliary drain exchange and underscores the value of real-time fluoroscopic recognition and management. It is essential that clinicians performing these procedures are aware of this potential complication to ensure patient safety. To our knowledge, this is the first reported case of iatrogenic intussusception during biliary drain exchange managed successfully with hydrostatic reduction.