Case of the Month, January 2018

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


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

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.


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

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