A Case of Refractory Peptic Ulcer with Choledochoduodenal Fistula Successfully Treated by Biliary Stent Placement...

Choledochoduodenal fistula (CDF) is an abnormal communication between the common bile duct and the duodenum. While gallstones are the primary cause, peptic ulcer-related CDF has become rare due to the widespread antiulcer therapy. Nevertheless, CDF remains clinically relevant as symptoms are often vague and diagnosis is frequently incidental. We report the case of a 79-year-old woman with vomiting, epigastric pain, and back pain due to a refractory duodenal ulcer complicated by CDF. Endoscopic retrograde cholangiopancreatography (ERCP) using a standard duodenoscope was attempted to facilitate fistula closure by biliary stent placement; however, scope passage was prevented by severe duodenal stenosis. Therefore, ERCP was successfully performed using an ultrathin endoscope with a rendezvous technique. A guidewire was advanced through the CDF into the biliary tract and retrieved at the major papilla. Subsequently, a 5-Fr double-pigtail plastic stent was placed in the left intrahepatic bile duct. This approach achieved effective biliary drainage, promoting ulcer healing and complete fistula closure without surgery. The patient was discharged without complications. This case highlights the clinical utility of the ultrathin endoscope-assisted rendezvous ERCP as a minimally invasive option for CDF with duodenal obstruction when conventional ERCP is not feasible.