Choledocolithiasis - passed stones

Case contributed by Dr Bruno Di Muzio

Presentation

RUQ and epigastric pain + jaundice. Obstructing stone? cholecystitis?

Patient Data

Age: 55 years
Gender: Female
Ultrasound

Abdomen

Multiple non-obstructing calculi noted in the gallbladder fundus. The gallbladder is distended and tender to probe, but the wall is not thickened (2mm). No pericholecystic fluid.
2 calculi in the CBD, measuring 20 x 8mm and 6 x 4mm. The CBD is mildly dilated (7mm).

The pancreas is not well visualized but the main pancreatic duct measures
\R\20mm in diameter. The intrahepatic ducts are not dilated.

The liver, kidneys, spleen, and aorta are unremarkable. Small renal cyst in the left lower pole. No ascites.

Conclusion: Cholelithiasis and choledocholithiasis - with 2 calculi seen in the common bile duct. Tender gallbladder without sonographic features of cholecystitis.

CT

Intravenous cholangiogram

There is no biliary tree dilatation, the common bile duct measures up to 5.5 mm in caliber.  Tapering of the very distal common bile duct, at the level of the papilla, does not have worrisome features, no evidence of intraductal stones.  There is normal spillage of contrast into the duodenum. The gallbladder is not abnormally distended and shows multiple gallstones.  The cystic duct is normal.  The remainder of the imaged superior abdomen is unremarkable for this targeted protocol.

Conclusion: The previously demonstrated CBD stones have passed, no biliary obstruction or residual intraductal stones on the images of today.

  • Bilirubin 54 mcmol/L
  • ALT 975 units/L
  • GGT 230 units/L
  • ALP 260 units/L
  • lipase 8220 units/L

Diagnosis of gallstones pancreatitis was made. The patient was referred to the surgical unit and was planned for ERCP.

Two days later:

  • Bilirubin 17 mcmol/L
  • ALT  450 units/L
  • GGT 125 units/L
  • ALP 152 units/L

CT IVC recommended before ERCP (no MRI scanner available ins this rural hospital). 

 

 

Case Discussion

A case demonstrating choledocholithiasis on ultrasound and subsequent down-trending LFTs and bilirubin, with CT intravenous cholangiogram confirming passed stones. 

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Case information

rID: 72030
Published: 19th Apr 2020
Last edited: 19th Apr 2020
Inclusion in quiz mode: Included

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