Radiolucent gallstones

Case contributed by Dr Vitalii Rogalskyi

Presentation

Sudden onset of right upper quadrant pain and jaundice. Rule out gallstones or pancreatic tumor.

Patient Data

Age: 60 years
Gender: Female

CT abdomen

CT

Biliary duct dilatation up to distal part of common bile duct with no visible stones. The pancreas is unremarkable without signs of tumor or ectasia of the duct of Wirsung.

A hepatic cyst is noted at each lobe, larger on the right lobe. 

Left renal angiomyolipoma noted (contains macroscopic fat).

CT

Bile duct dilatation without visible obstruction.

So, CT shows no gallstone disease or pancreatic head tumor. We decided to perform endoscopic retrograde cholangiopancreatography (ERCP). 

ERCP

Photo

ERCP shows a lot of gallstones within the common bile duct.

Case Discussion

Acute right upper quadrant pain and fever are very suspicious for choledocholithiasis. But always remember about radiolucent gallstones that are isodense to bile and may not be identified on x-ray or CT, as in this case. 

So, if gallstones on CT are not seen, then other modalities such as US, MRI or ERCP should be considered, which are more sensitive for calculi.

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