Albert Einstein Healthcare Network/Digestive Disease and Transplantation Philadelphia, Pennsylvania
Alexander Pop, MD1, Pilin D. Francis, DO2, Lisa Barrett, DO2, Michael E. Goldberg, DO2; 1Albert Einstein Healthcare Network/Digestive Disease and Transplantation, Philadelphia, PA; 2Einstein Healthcare Network, Philadelphia, PA
Introduction: Gallstones are a frequent diagnosis in the general population. While mostly asymptomatic, they can sometimes lead to serious complications of biliary obstruction, sepsis, and rarely death. While most cases of choledocholithiasis can be managed via procedures such as endoscopic retrograde cholangiopancreatography (ERCP), larger stones may be more difficult to address. We present a case of cholangitis brought upon by giant choledochal stones.
Methods: A 75-year-old woman with a past medical history of hypertension presented with abdominal pain. Symptoms began two to three days prior to assessment. Pain was most pronounced in the right upper quadrant and associated with nausea and vomiting. She reported subjective fevers and chills. Family also noted that she had become more “yellow” over the past few days. Pt denied history of viral hepatitis or over the counter supplement use. She had a cholecystectomy in 2015. Family denied a history of cancer. In the Emergency Department vitals were significant for a fever of 38.6 Celsius. Physical examination was notable for right upper quadrant tenderness. On laboratory work alkaline phosphatase was 320 with a total bilirubin of 7.1. ALT and AST were 138 and 172, respectively. INR was 1.2. Contrast CT abdomen and pelvis showed extrahepatic bile duct dilation measuring 3.5 cm and two ovoid densities measuring 2 cm and 3.8 cm suspicious for calculi/sludge balls. She underwent ERCP with incomplete stone extraction due to large size of the remaining stone (3cm) and biliary stent placement for decompression. Following ERPC pain improved, fevers resolved, and liver function tests trended down. She was scheduled for repeat ERCP outpatient for stone removal and stent retrieval. Discussion: Gallstones may be asymptomatic or can manifest as simple biliary cholic. Rarely patients present more severely with cholecystitis, gallstone pancreatitis, or cholangitis. In the case of cholangitis patients can develop jaundice, fever, and right upper quadrant abdominal pain. Diagnosis is aided by an obstructive pattern in liver function tests and is made via ultrasound, MRI imaging, and sometimes CT imaging. This case shows that stones in the biliary tree can reach considerable dimensions before causing serious symptoms. In the patient presenting with cholangitis brought upon by giant choledochal stones repeat ERCP may be necessary to complete stone extraction after biliary decompression has been achieved.
Gall Stone, Coronal
Gall stones, Coronal
Disclosures: Alexander Pop indicated no relevant financial relationships. Pilin Francis indicated no relevant financial relationships. Lisa Barrett indicated no relevant financial relationships. Michael Goldberg indicated no relevant financial relationships.