Case of the Month, January 2018

Submitted by Jordan Gutovich, MD and Thomas Learch, MD.

Presentation

An 84-year-old man presented to the emergency room with mild epigastric discomfort and abdominal distention without fever, vomiting or diarrhea. On exam, the patient had scleral icterus; his abdomen was non-tender to palpation.

Laboratory analysis demonstrated:

  • Total bilirubin of 13.3
  • Direct bilirubin of 11.6
  • AST of 258, and
  • ALT of 258 
  • Of note, alkaline phosphatase was 718 
  • Lipase was normal
Imaging

The patient underwent a CT scan of his abdomen and pelvis. 

Figure 1

Imaging revealed marked dilation of both the intra and extrahepatic biliary tree (Figure 1).  There was also occlusion of the left portal vein by a dilated left biliary tree with subsequent heterogeneous perfusion of the left hepatic lobe (Figure 1 arrow).

Figure 2

Hyperdense material was present at the distal common bile duct (Figure 2 arrow).  Differential considerations included biliary sludge/stones as well as ampullary neoplasm.

Figure 3

The patient ultimately underwent endoscopic retrograde cholangiopancreatography (ERCP) where multiple well rounded filling defects were seen in the common bile duct (Figure 3 arrows) that were found to be large stones. No malignancy was identified.

Diagnosis

Choledocholithiasis with severe intra and extrahepatic dilatation secondary to biliary obstruction by large stones in the common bile duct.

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