Sump Syndrome

Sump syndrome is recurrent cholangitis, pancreatitis or biliary stones caused by stasis and debris collecting in the distal common bile duct (the sump) after a side-to-side choledochoduodenostomy, and less often after a choledochojejunostomy.

It is uncommon, with an estimated incidence of a few percent after side-to-side choledochoduodenostomy, and it may appear months to years after surgery, even decades later. Choledochoduodenostomy is used today mainly for difficult common bile duct stones and benign obstruction.

Pathophysiology.

Bile drains into the duodenum through the anastomosis, leaving the distal duct as a blind segment. Food, debris, stones and sludge accumulate in this segment and cause obstruction of the ampulla and of the pancreatic duct, with ascending infection.

Right upper quadrant pain, fever and jaundice (cholangitis), recurrent acute pancreatitis, raised liver enzymes and, occasionally, liver abscess. Symptoms often recur after a long quiet period.

Red flags.

• Fever with rigors and jaundice.
• Septic shock.
• Severe pancreatitis.
• Liver abscess.

Liver tests, lipase and blood cultures. Ultrasound shows dilated ducts with pneumobilia. Magnetic resonance cholangiopancreatography shows the anastomosis and sump with stones or debris. Endoscopic retrograde cholangiopancreatography confirms and treats. Exclude malignancy of the duct or ampulla.

Differential diagnosis.

• Anastomotic stricture.
• Recurrent common bile duct stones.
• Biliary malignancy.
• Pancreatitis from other causes.
• Intrahepatic stones.

Treat cholangitis first.

• Piperacillin-tazobactam: 4.5 g IV every 6 hours for 4 to 7 days after drainage; maximum 18 g daily; monitor renal function and blood counts; reduce for creatinine clearance under 40 mL/min.

Endoscopic sphincterotomy of the papilla with stone and debris clearance is the preferred treatment, since it drains the sump into the duodenum. Insert a stent if clearance is incomplete. Surgery (conversion to a Roux-en-Y hepaticojejunostomy, or excision of the sump) is used for failed endoscopic treatment or when the anastomosis is itself stenosed.

Give indomethacin for pancreatitis prophylaxis: 100 mg rectally once before or after ERCP; maximum 100 mg; monitor renal function and bleeding; avoid in peptic ulcer, renal impairment and non-steroidal drug allergy.

Monitoring. Liver tests at 4 to 6 weeks, then at symptoms; imaging yearly if recurrence risk is high.

Referral and escalation. Pancreaticobiliary endoscopy and hepatobiliary surgery; critical care for septic shock.