recently , endoscopic papillotomy ( e.p.t . ) has achieved wide acceptance as an alternative to surgery for the management of choledocholithiasis . however , there are several of problems , one of which relates to the size of the stone .
a stone larger than 2.5 cm in diameter has been regarded as a contraindication of endoscopic papillotomy due to complications and frequent failures . a new method in which the stone is partially crushed in place and then extracted has been developed and has been successfully used on large stones .
we experienced a patient who had a cholecystectomy and presented with a very large stone ( 6  2  2 cm ) ( fig .
although endoscopic papillotomy was contraindicated in this case , it was performed with the usual lithotripter , because the patient refused surgery .
a 34 year - old man was admitted to the department of internal medicine complaining of a colicky right - upper abdominal pain accompanied by chills and fever of 2 days duration .
he was healthy until 5 months earlier when he experienced the abrupt onset of right - upper abdominal pain accompanied by mildly icteric sclera . under the impression of postcholecystectomy syndrome ,
endoscopic retrograde cholangiopancreatography was performed which revealed a large stone in the distal common bile duct .
endoscopic papillotomy and irrigation of common bile duct were done in the endoscopic room at that time .
thereafter he was healthy until 2 days prior to his present admission , when right - upper abdominal pain accompanied by chills , fever and cold sweats recurred .
all vital signs were within normal limits except body temperature which was 38c . on physical examination his sclera was icteric , the hepatic edge was not palpable and no other abnormal findings were noted .
laboratory data included wbc 11,600 with 76% neutrophils ; alkaline phosphatase , 21.6 ka / u ( normal 2.710 ) ; serum asparate aminotransferase ( got / gpt ) , 351/318 iu./l ; and total bililubin / direct bililubin 3.7/1.5 mg / dl .
initially the patient s condition was diagnosed as obstructive jaundice with cholangitis . on the 2nd hospital day
, endoscopic retrograde cholangiography was performed revealing a large stone ( 622.0 ) ( fig .
1 ) in the common bile duct which was partially removed by endoscopic papillotomy and lithotripsy with irrigation . 4 days later , right - upper abdominal pain returned and a follow - up e.r.c.p . showed a large stone ( 333 ) impacted in the orifice of the papillotomy site ( fig .
after widening the papilla by cauterization and incision a wire was inserted through the papillotomy site into the bile duct , and by repeated crushing and extraction the remaining stones were removed ( fig .
3 ) . the e.r.c.p . performed 2 days after those procedures showed air bubbles in the common bile duct but no definite stone shadows were visualized ( fig .
the development of endoscopic retrograde cholangiography as a diagnostic tool for biliary tract and pancreatic disease , has resulted in nonsurgical treatment for diseases of the biliary tract ( 14 , 8) . since endoscopic papillotomy was performed succefully in 1973(9 ) ,
it has also contributed to the therapeutic procedures for common bile duct stone and papillary stenosis .
the main indication for endoscopic papillotomy is the extraction of common bile duct stones from cholecystectomized elderly or high risk patients .
however , endoscopy should not be routinely performed in patients with common bile duct stones larger than 2.5 cm in diameter because of complications and frequent failures ( 5 , 6 ) .
following papillotomy the majority of common bile duct stones were extracted with the aid of a basket or passed spontaneously ( 6 ) , but more than 10% of the stone were not extracted easily due to their large size or a narrowing of the bile duct above the papilla . although there is a report that some large stones may pass spontaneously ( 10 , 11 ) , most can not be extracted despite a large papillotomy which may result in complications . to overcome these problems , nonsurgical mechanical procedures such as electrohydraulic lithotripsy , dissolution therapy , and lithotripter have been developed with varing sucess(12 ) .
while ejectrohydraulic lithotripsy and dissolution therapy have failed to gain wide acceptance because of technical problems and adverse reactions(13 , 14 ) , mechanical lithotripsy has proved to be of value(14 , 15 ) . presently some centers report a high suscess rate(97% ) with few complications using this method(12 ) .
it is difficult to conclude that the endoscopic papillotomy is always more effective than surgical procedures for the treatment of common bile duct stones ( including large ones ) , but it has definite advantages in some selected cases .
 a previously cholecystectomized man presented on endoscopic retrograde cholangiography with a large stone ( 622 cm ) in the common bile duct.the patient refused surgical removal of the stone , so although endoscopic papillotomy was contrainicated , it was attempted . 
 herein is presented a case report of successful removal of a large stone by endoscopic papillotomy and lithotripsy with no significant complications . 
INTRODUCTION
REPORT OF CASE
DISCUSSION