Endoscopic ultrasound-guided gallbladder drainage using a lumen-apposing
metal stent has emerged as an accepted option for the treatment of
acute cholecystitis in patients unfit for surgery. While
metal stents carry a risk of intra- and post-procedural
bleeding, the coaxial placement of a double-pigtail
stents through lumen-apposing
metal stents has been proposed to lower the
bleeding risk by preventing tissue abrasion against the
stent flanges. We present a case of an 83 year-old male who had previously undergone uncomplicated endoscopic ultrasound-guided cholecystoduodenostomy with this technique. Six months later, he presented with upper gastrointestinal
bleeding due to a duodenal
pressure ulcer from the coaxial 10-Fr double-pigtail
stent originally employed to prevent such
bleeding. The 10-Fr
stent was replaced with two 7-Fr
stents whose increased flexibility and distribution of pressure across multiple points of contact with the duodenal wall was theorized to reduce the likelihood of erosion or perforation. Following the procedure, the patient's
clinical course improved significantly with complete resolution of his symptoms of
choledocholithiasis and
cholecystitis. While 10-Fr double-pigtail
stents are generally preferred for this indication due to their stiffness that reduces out-migration, use of more flexible 7-Fr
stents may be advisable in thin-walled structures such as the duodenum.