Icahn School of Medicine at Mount Sinai Jamaica, NY
David D. Zheng, MD, Saphwat Eskaros, MD, Negar Niknam, MD; Icahn School of Medicine at Mount Sinai, Jamaica, NY
Introduction: Obstructive jaundice can be caused by various etiologies such as choledocholithiasis, malignancies, strictures, extrinsic compression, haemobilia and even parasites. We present here a case of obstructive jaundice with severe hyperbilirubinemia caused by choledocholithiasis that was successfully treated with stone removal via ERCP.
Methods: A 66 year old man with no significant past medical history presented with worsening jaundice, epigastric pain, weight loss and nausea for two months prior to presentation. Upon presentation, patient was markedly jaundiced with unremarkable abdominal exam and no evidence of pancreatitis or cholangitis. Labs were remarkable for total bilirubin 78.6mg/dL, direct bilirubin >20mg/dL, ALP 1699U/L, ALT 239U/L, AST 237U/L, CA19-9 1228U/mL. Viral hepatitis panel was negative. CT of abdomen/pelvis showed 1.3 x 1.0cm obstructive calculus at the distal common bile duct, marked intra and extra hepatic biliary ductal dilatation and cholelithiasis. During ERCP, a large oval stone was found impacted in the distal common bile duct (CBD) with marked up stream dilation of bile duct. The stone was successfully removed after sphincterotomy with mechanical lithotripsy and balloon sweeps. Due to high suspicion for malignant etiology in the setting of extreme hyperbilirubinemia and elevated CA19-9, brushing of CBD was performed for cytology which was negative for malignancy. Subsequently, patient’s clinical status and lab results improved. On follow up appointments, patient was completely asymptomatic. Repeat abdominal MRI/MRCP were negative for any malignancy in the abdomen. Cholelithiasis was found without dilated biliary system or choledocholithiasis. LFTs, bilirubin and CA19–9 completely normalized. Patient was referred for cholecystectomy. Discussion: Patients with biliary obstruction mostly present with abnormal LFTs and elevated bilirubin level. To our knowledge, hyperbilirubinemia to this extent has not been reported solely due to a benign obstruction caused by choledocholithiasis. In patients with underlying liver diseases such as alcohol induced hepatitis, liver injury or malignancy, the LFTs and bilirubin are generally higher compare to benign etiologies. However, this patient had no other underlying disease and recovered completely after resolution of obstruction. Significant elevation of CA19-9 and hyperbilirubinemia in this patient appears to be secondary to complete or near obstruction of CBD due to impacted stone.
Dilated biliary tree with obstructing choledocholithiasis
ERCP findings of dilated biliary tree and obstructive stone
Disclosures: David Zheng indicated no relevant financial relationships. Saphwat Eskaros indicated no relevant financial relationships. Negar Niknam indicated no relevant financial relationships.