The use of a fully covered metal stent during ERCP is a common and effective solution for biliary drainage in cases of choledocholithiasis [7]. However, in patients with an intact gallbladder, the placement of such stents can introduce complications [8]. Fully-covered stents have a significant risk of obstructing the cystic duct orifice, particularly in patients with a low cystic duct junction [9]. This anatomical feature occurs in over 33% of cases, making it a critical factor to consider during stent placement [10,11]. When the cystic duct becomes obstructed, bile cannot drain from the gallbladder, leading to bile stasis and acute cholecystitis [12]. Without timely intervention, this can escalate into more serious complications, such as gallbladder rupture, as seen in this case [13]. While the use of fully covered metal stents in managing choledocholithiasis is common, cases like this one, where the stent placement led to cystic duct obstruction and subsequent gallbladder rupture, remain rare. Comparatively, most documented cases involving ERCP and stenting complications tend to present with acute cholecystitis rather than progressing to rupture and abscess formation [2].

Once the gallbladder ruptures, the potential for serious complications increases dramatically [14]. In this case, bile and bacteria leaked from the gallbladder into surrounding structures, forming a fistula between the gallbladder and the liver [13]. This direct communication allowed the spread of infection into the liver parenchyma, resulting in a large hepatic abscess [15]. Gallbladder ruptures are rare, but when they occur, they often lead to the development of liver abscesses, which are polymicrobial in nature [16]. Streptococcus anginosus, a frequent pathogen in biliary infections, was cultured from this patient’s abscess, consistent with the fistulous connection between the inflamed gallbladder and the liver [17,18]. Imaging, including ultrasound and CT, played a crucial role in diagnosing both the gallbladder rupture and the liver abscess, guiding the therapeutic approach [19].

ERCP with sphincterotomy and stone extraction remains the cornerstone of treatment for choledocholithiasis [1]. However, the decision to place a fully-covered metal stent in patients with an intact gallbladder requires careful consideration due to the risk of cystic duct occlusion [6]. In some cases, a prophylactic cholecystectomy should be considered, especially when the anatomy suggests a high likelihood of the stent covering the cystic duct [20]. In patients with pancreatic ductal adenocarcinoma (PDAC) or distal cholangiocarcinoma, the same risk exists when metal biliary stents are used, often resulting in fevers, chills, and right upper quadrant pain due to the blocked cystic duct [9]. Therefore, in patients receiving fully-covered metal stents, vigilant monitoring and consideration of surgical intervention are critical to prevent severe outcomes like obstructive cholecystitis or, as in this case, gallbladder rupture [21].

After the liver abscess was identified, prompt percutaneous drainage under CT guidance was performed to reduce the risk of further infection and sepsis [19]. Drainage remains the gold standard for managing large abscesses, especially when surgical resection is not feasible [15]. Coupled with targeted antibiotic therapy, drainage is critical for preventing the spread of infection and ensuring resolution [17]. In this case, the patient was initially treated with broad-spectrum antibiotics, including piperacillin-tazobactam, followed by a course of oral amoxicillin-clavulanate to cover the common biliary pathogens identified in the abscess culture. The prolonged antibiotic therapy helped prevent recurrence and allowed for a full recovery from the infection.

Complicating the course of this patient’s condition was the development of portal vein thrombosis, a recognized but serious complication of hepatobiliary infections [22]. Severe inflammation and infection within the liver can create a hypercoagulable state, increasing the risk of thrombosis in nearby vascular structures [23]. Portal vein thrombosis can lead to complications such as bowel ischemia or portal hypertension if left untreated [24]. In this case, therapeutic anticoagulation was initiated early to prevent these complications and promote resolution of the thrombosis.

Here, we illustrate the potential dangers associated with stent placement in patients with an intact gallbladder. The stent induced obstruction of the cystic duct, leading to gallbladder rupture. While ERCP remains an essential tool in managing choledocholithiasis, we must remain vigilant for post-procedure complications, particularly in patients receiving fully-covered stents. Early identification of complications such as liver abscesses and portal vein thrombosis, along with appropriate interventions like drainage and anticoagulation, are essential to ensure favorable outcomes in these complex cases. Alternative approaches, such as using partially covered or plastic stents, may reduce the risk of cystic duct obstruction in patients with an intact gallbladder. In high-risk cases, a prophylactic cholecystectomy could also be considered to prevent complications associated with stent-induced cystic duct occlusion.