Impacted biliary stone at the duodenal papilla

Case contributed by Dr Bruno Di Muzio

Presentation

Epigastric pain, significant derangement LFTs. Pancreatitis? Choledocholithiasis? Liver disease?

Patient Data

Age: 72 years
Ultrasound

Ultrasound of the upper abdomen

Liver, spleen and pancreas have a normal appearance. No focal liver lesion. Patient reports a cholecystectomy. Common bile duct measures 12 mm. Intrahepatic duct dilatation. Both kidneys have a normal appearance - the right kidney measures 10.2 cm and the left kidney measures 11.1 cm.

Conclusion: Intra and extrahepatic duct dilatation, more than expected for age/ cholecystectomy. No choledocholithiasis identified.

There is marked intra and extra great duct dilatation with the common hepatic duct measuring up to 16 mm in diameter. The pancreatic duct is also dilated measuring approximately 7 mm at the pancreatic head. No obstructing lesion is identified within the ampulla on dedicated MRCP imaging. On unenhanced sequences, there is no lesion within the pancreatic head. The pancreatic duct distally is dilated without regions of stricturing. Small T2 hyperintense lesions within the pancreatic tail appear continuous with the pancreatic duct and likely represent small IPMN measuring 12mm. No focal hepatic lesion identified. The remaining imaged upper abdominal organs are unremarkable. Possible posterior basal left lower lobe 6 mm nodule.

Conclusion: Marked intra and extra hepatic duct dilatation as well as enlargement of the pancreatic duct. An obstructing calculus is seen in the common channel created by the CBD and pancreatic duct. Possible left lower lobe 6 mm lung nodule can be further characterised with CT. 7 cm pelvic mass could be confirmed as a fibroid uterus with US if required.

CT

CT Abdomen (pancreas)

There is a 7 mm stone at the level of the duodenal papilla causing upstream intra and extra-hepatic biliary tree dilatation and main pancreatic duct dilatation, as previously demonstrated on the MRCP images. Metallic surgical clips of cholecystectomy in the gallbladder fossa. The liver and pancreas are otherwise unremarkable, with no suspicious lesions. A few scattered pancreatic parenchymal calcifications noted. No suspicious enlarged lymph nodes. Apart from a small calcified granuloma, the spleen has normal appearances. Adrenal glands, imaged portions of the kidneys and bowel loops are unremarkable. Pleural bases are clear. The left lower lobe pulmonary nodule measuring 7 mm is partially calcified.

Conclusion: Stone at the level of the duodenal papilla causing biliary tree and pancreatic duct dilatation as previously demonstrated in the MRCP study. No evidence of pancreatic malignancy. Left lower lobe pulmonary nodule has benign appearances and does not require further follow-up.

Case Discussion

This case illustrates a calcified stone at the level of the duodenal papilla causing biliary tree and pancreatic duct dilatation. 

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Case information

rID: 53293
Case created: 11th May 2017
Last edited: 12th Jun 2017
Tag: rmh
Inclusion in quiz mode: Included

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