A 71-year-old woman was referred to our department with abdominal pain and jaundice. She had surgery for early gastric cancer and cholecystolithiasis at the age of 67. At that time, she underwent cholecystectomy, distal gastrectomy, and Roux-en-Y gastrojejunostomy.
At the age of 69, she suffered from acute obstructive cholangitis due to cystic duct and bile duct stones. Peroral endoscopic stone removal was attempted but failed. So, she underwent laparoscopic choledochotomy and T-tube bile drainage. One month after surgery, the papilla of Vater was dilated to 11 mm in diameter by endoscopic papillary balloon dilatation using the rendezvous technique. Two months after the removal of the T-tube, residual stones were found. Peroral endoscopic stone removal was retried but failed again. After that, she was followed up at our hospital.
On admission, her temperature was 38.2 C and her blood pressure was 141/85 mmHg. Her height was 160 cm, body weight was 41.3kg, and body mass index was 16.1 kg/m2. She had tenderness in her right hypochondrium. Laboratory results showed hemoglobin 12.6 g/dL (normal range, 11.0-14.6), white blood cell count 3900 /microL (3500-8000), platelet count 13.2 x 104 /microL (12.3-33.1), total bilirubin 5.8 mg/dL (0.3-1.3), alanine aminotransaminase 239 IU/L (10-32), aspartate aminotransferase 560 IU/L (5-27), alkaline phosphatase 242 U/L (38-113), gamma-glutamyl transpeptidase 166 U/L (11-64), serum amylase 738 IU/L(28-99), blood urea nitrogen 12.2 mg/dL (8-20), creatinine 0.55 mg/dL (0.36-1.06), prothrombin time (PT) 12.6 sec (9-12), PT% 84.1% (70-130), international normalized ratio 1.1, activated partial thromboplastin time 23.7 sec (20-35), procalcitonin 5.56 ng/mL (0-0.49), C-reactive protein 11.97 mg/dL (<0.16), and brain natriuretic peptide 23.4 ng/mL (0-18.4). Based on the clinical findings and laboratory workup, acute obstructive cholangitis with sepsis was suspected and was treated with a systemic antibiotic.
Abdominal ultrasonography (US) showed high-echoic stones in the dilated bile duct. Contrast-enhanced abdominal computed tomography (CT) showed multiple stones in the cystic duct, common hepatic duct, and common bile duct with biliary dilatation and duodenal parapapillary diverticulums (Figs. 1A and B). The abdominal magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography (MRCP) also showed multiple stones of varying sizes (8, 17, and 14mm, respectively) in the cystic duct, common hepatic duct, and common bile duct (Figs. 2A and B).
Percutaneous transhepatic biliary drainage (PTBD) was planned on the 2nd day of hospitalization. Before PTBD, color Doppler US was performed to avoid vessel puncture. Initial percutaneous transhepatic cholangiography through the right anterior hepatic duct revealed a large stone in the common hepatic duct (Fig. 3A). After introducing a guidewire into the bile duct through the puncture needle, a 10 Fr. PTBD tube was inserted into the common hepatic duct using a 2-step method. A second cholangiogram through the PTBD tube revealed multiple stones in the cystic duct, common hepatic duct, and common bile duct (Fig. 3B). The culture of bile showed the presence of Escherichia coli, Klebsiella oxytoca, and Enterococcus raffinosus. The culture of blood showed the presence of E coli, and Klebsiella pneumonia sensitive to a given antibiotic.
Two days after PTBD, alkaline phosphatase, an indicator of cholestasis, normalized to 103 U/L. Ten days after PTBD, the cholangitis was relieved, and the patient was temporarily discharged with the PTBD tube left in situ. She was readmitted 5 weeks after PTBD, and the PTBD route was dilated to 18 Fr. Six weeks after PTBD, she was treated by stone removal with PPBD using an 8 Fr. cobra-shaped sheath and cholangioscopy. The papilla of Vater was dilated with a balloon 12 mm in diameter for 10 minutes at 2 atm (Fig. 4A). Common hepatic and bile ducts stones were crushed by electrohydraulic lithotripsy (EHL) and then pushed out into the duodenum through the dilated papilla of Vater using a 6 Fr. balloon catheter covered with the sheath and cholangioscopy (Fig. 4B). The cystic duct stone was observable with a cholangioscope (Figs. 5A and A*), but the bending of the cholangioscope made it difficult to insert the EHL probe into the optimal position. For stone located in the cystic duct, a 5 Fr. balloon catheter was inserted into the cystic duct following a guidewire by using the cobra-shaped sheath (Fig. 5B). The balloon was inflated and the stone was pulled into the common bile duct (Fig. 5C). Then the stone was pushed out into the duodenum. Clearance of cystic duct and bile duct stones was confirmed by balloon-occluded cholangiography using a cobra-shaped sheath and a 6 Fr. balloon catheter (Fig. 5D). After that, cholangiomanometry was performed. The resistance and residual biliary pressure values at zero flow rate were 5 units (normal range, 1-7) and 11.5 cmH20 (normal range, 5-15), respectively. These values were not considered abnormal by the Nagakawa criteria. Infrared spectroscopy revealed that more than 95% of the bile duct stone component was bilirubin calcium. She was discharged 3 days after percutaneous stone removal. Ten days after percutaneous stone removal, the PTBD tube was removed after confirming that the cystic duct, common hepatic, and common bile ducts were free of stones on MRCP and final cholangiography (Figs. 6A and B).