A Ureteric Double J stent is a commonly used in various urological procedures. Many complications related to this like migration into kidney or blabber, encrustation, infection etc. are well known. Similarly, misplacement of Double J stent (partly or completely) in extraurinary system (e.g. retroperitoneum, vascular, colon) is a well-known complication. There are only two case reports of misplacement of DJ stent in duodenum. We are presenting a case of misplaced and forgotten right DJ stent in second part of duodenum that was successfully managed conservatively contrary to invasive approach as previously reported in literature.

A 50year diabetic male presented in outdoor with complaints of terminal dysuria and epigastric discomfort. He had a history of right DJ stenting 1.5year back at another hospital for right calculus pyonephrosis during covid period. Patient lost to follow-up and presented to us with above complaints. He was evaluated for the same and found to have small contracted right kidney with upper end of DJ stent in second part of duodenum. There was also a calculus formation at the vesical end of DJ stent.

After cystolithotripsy, DJ stent was gradually pulled gently under fluoroscopic guidance keeping a watch on straightening of the upper end of the DJ stent. Patient was closely monitored and kept nil orally for 48 hours. As there were no periprocedural complications, patient was discharged after 72hours. Patient is doing well on 24months of follow up.

Lessons learned from this case are 1) DJ stent should be inserted under fluoroscopic guidance and RGP should be a routine 2) Undue force in inserting guidewire should be avoided 3) In case of a misplaced duodenal stent in second part of duodenum piercing its posterior wall can be managed conservatively avoiding invasive major procedures.