Presentation
Two to three days of diarrhea, abdominal pain and fevers. Gram negative bacteremia.
Patient Data
Distended thin-walled gallbladder without cholelithiasis or pericholecystic fat stranding.
Two rounded hyperdensities within the distal common bile duct (CBD) consistent with biliary calculi measure 10mm superiorly and 6mm inferiorly (axial, coronal, sagittal). Marked proximal dilatation of the CBD up to 19mm in diameter. Marked intrahepatic ductal dilatation outlining the left and right hepatic hepatic ducts. Marked dilatation of the branching left and right portal veins.
The hepatic parenchyma itself appears normal. The hepatic, portal and splenic veins are patent. No pancreatic duct dilatation or fat stranding to suggest secondary pancreatitis.
No abnormally dilated loops of small or large bowel. No abnormal bowel wall thickening or enhancement. No intra-abdominal free gas or fluid.
Conclusion
Choledocholithiasis in the context of gram negative bacteremia, concerning for ascending cholangitis. Urgent surgical review is commended.
Case Discussion
This 85-year-old woman presented with generalized abdominal pain, fevers and diarrhea. She was found to have raised serum inflammatory markers and cholestatic liver function derangement. In the context of bacteremia, urgent imaging was requested to look for an intra-abdominal source of sepsis.
CT of the abdomen and pelvis confirmed choledocholithiasis, which in this clinical context reflects biliary sepsis secondary to ascending cholangitis. Blood cultures were positive for both Eschericia coli and Streptococcus canis bacteria.
She was treated with IV antibiotics and underwent ERCP where two calculi and pus were extracted from the CBD. A temporary biliary stent was placed with plan for removal in 3 months. The patient recovered well and was discharged home on oral antibiotics.
Interestingly, this patient did not fulfill Charcot's triad of ascending cholangitis despite the two very large obstructing CBD stones. She had a fever and right upper quadrant pain but lacked clinical jaundice. Her serum bilirubin was 11µmol/L, though the ALP and GGT were 2-3x the upper limit of normal.
This case nicely demonstrates the anatomy of the biliary tree. The portal vein, hepatic artery and intrahepatic bile ducts branch together throughout the hepatic parenchyma.
Case courtesy of Dr Brigitte Russel.
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