Case Presentation: Sump syndrome is a rare complication of side-to-side choledochoduodenostomy (CDD). CDD used to be a common surgical procedure done in the era before endoscopic retrograde cholangiopancreatography (ERCP). After side-to-side CDD, the CBD between the anastomosis and the ampulla of Vater becomes a potential sump (a recess or reservoir serving a drain for liquids). Ascending cholangitis and pneumobilia decades after the initial CDD lead to the suspicion of a sump syndrome as illustrated in our patient below. 

A 64 year-old male with type 2 diabetes mellitus, hypertension, dyslipidemia, benign prostatic hypertrophy, Parkinson’s disease, multiple hepatic abscesses, alcoholism, and past history of cholecystectomy and revision of CBD (in 1980 in  Mexico) presented to emergency room with sharp epigastric pain radiating to the RUQ, fever and recurrent vomiting for two days. He was febrile, tachycardic, hypotensive, and had RUQ abdominal tenderness. Labs revealed leukocytosis, elevated alkaline phosphatase, and elevated  transaminases. He was started on IV fluids and antibiotics. An ERCP revealed a small orifice proximal to the papilla of Vater. Air insufflation into this orifice induced pneumobilia; contrast injection showed drainage of the contrast dye via the anastomosis, confirming the CDD. Filling defects of the distal CBD revealed impaction of abundant debris and drainage of pus. Ascending cholangitis in the context of a CDD together with the endoscopic picture of filling defects in the distal CBD led to the diagnosis of sump syndrome. Sphincterotomy and stenting was performed. He recovered and was discharged home.

Discussion: The term “sump syndrome” was coined after the observation of accumulated debris proximal to the papilla, in the distal bile duct reservoir of affected patients. In the pre-ERCP era CDD was a common surgical procedure in patients with biliary tract disease. In the setting of a side-to-side CDD the bile does not drain through the distal CBD anymore. Therefore the part of the CBD distal from the CDD anastomosis consequently transforms into a poorly drained reservoir, making this so-called ‘sump’ prone to accumulation of debris. Sump syndrome results from accumulation of lithogenic bile, debris or calculi as well as refluxed duodenal contents in the distal CBD, leading to biliary and/or pancreatic complications. The diagnosis of sump syndrome often becomes clinically manifest several decades after the initial CDD. A detailed medical history and pneumobilia are important elements for diagnosis.  

Sump syndrome can be treated by biliary sphincterotomy and extracting the debris from the CBD though ERCP and also surgically by creating a Roux-en-Y hepaticojejunostomy.

Conclusions: It is important to include sump syndrome in the differential diagnosis for patients who present with cholangitis with history of cholecystectomy in pre ERCP era or if patients are from developing country.