Choledocholithiasis

Case contributed by Dr Michael P Hartung

Presentation

Abdominal pain with elevated liver function tests.

Patient Data

Age: 55 years
Gender: Male
CT

Subtle rounded filling defects in the distal common bile duct. No biliary ductal dilation. 

Focal dilation/irregularity of the pancreatic duct in the head/near the ampulla. 

Fluoroscopy

ERCP

Rounded filling defects in the distal common bile duct, consisted with choledocholithiasis. These were removed with balloon sweep. 

Annotated coronal image

Common bile duct stones indicated with red arrows on this coronal CT image. Notice how they are easier to see with liver windows. 

Case Discussion

This case illustrates several important items:

  • choledocholithiasis can be very subtle and present with normal caliber common and intrahepatic ducts
  • correlation with liver function tests (suggesting obstruction) helped guide careful interrogation of the bile ducts
  • a more aggressive window/level setting (such a liver) may help you identify the stones; I personally find it easiest to use the coronal images (see annotated images)
  • MRCP is NOT needed; you can confidently make this diagnosis with CT. This patient can (and should) go directly to ERCP 
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Case information

rID: 71268
Published: 25th Sep 2019
Last edited: 9th May 2020
Inclusion in quiz mode: Included