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