The patient is a 57-year-old African American female with past medical history of hypertension and remote surgical history of cholecystectomy 33 years prior, who presented to another medical center with non-radiating sharp RUQ pain. The patient rated the pain as a 7 out of 10 and experienced associated nausea and vomiting and one episode of fever (102 F) with reduced appetite for two days prior to admittance. Initial laboratory tests were notable for WBC 13.500, AST 514 U/L, ALT 379 U/L, total bilirubin (TB) 2.7 mg/dl, lipase 497 U/L.
Abdominal-pelvic computed tomography (CT) imaging revealed a dilated common bile duct (CBD) of 2.2 centimeters with intrahepatic dilation and a prominent head of the pancreas. Magnetic Resonance Cholangiopancreatography confirmed the dilation of the CBD with distal tapering and showed a small volume of fluid around the liver and the CBD suggestive of cholangitis. The patient was started on IV broad spectrum antibiotics. Endoscopic Retrograde Cholangiopancreatography (ERCP) was performed and a protruding, swollen, enlarged ampulla with polypoid changes in the 2nd part of duodenum and localized attenuation of the bile duct were identified. A sphincterotomy was performed with copious biliary drainage. However, stent placement was unsuccessful.
The patient was then transferred to our medical center afebrile and hemodynamically stable. Repeat laboratory tests were notable for WBC 13,300, TB 1.8 mg/dl, ALK 228 U/L, AST 46 U/L, ALT 128 U/L, lipase 36 U/L. The prior biliary endoscopic sphincterotomy appeared open at repeat ERCP done by our GI endoscopist (BG). The cholangiogram showed that the left main hepatic duct, right main hepatic duct, common bile duct and common hepatic duct were moderately dilated. A filling defect consistent with a stone was seen on the cholangiogram. There was also a low lying cystic duct and long cystic duct remnant (Fig. 1). The biliary tree was swept and a trans-papillary dilation was performed. Sludge and stone fragments were removed. It was unclear if the stone fragments were completely removed, therefore a 10Fr x 7 cm plastic stent was placed into the common bile duct.
Subsequent double helical and pelvis contrast CT returned no findings of pancreatic head mass. Tumor markers (CEA, CA 125 and CA 19.9) were all found to be within normal limits.
The patient was discharged home on hospital day 4, after tolerating full enteral intake and after normalization of WBC, bilirubin, and lipase levels.
The biliary stent was endoscopically (ERCP) removed two months later without complications in an outpatient setting (Fig. 2).