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Choledocholithiasis

Leyla Azmoun, MD
Piran Aliabadi, MD
B Leonard Holman, MD

November 14, 1995

Presentation

A 62-year-old man presented with a 2-week history of intermittent right upper quadrant (RUQ) pain and a 2-day history of malaise, nausea and vomiting. Physical examination revealed a slightly jaundiced patient with tachycardia and mild RUQ tenderness without peritoneal signs. Laboratory evaluation was remarkable for a bilirubin of 4.1 and slightly elevated alkaline phosphatase.

Imaging Findings

Abdominal ultrasonography
Endoscopic retrograde stone extraction

Supine and upright abdominal radiographs were unremarkable.

Abdominal ultrasound scans show a mildly dilated common bile duct measuring 8 mm in diameter (arrow). An echogenic calculus with acoustic shadowing is visible in the distal portion of the common bile duct (arrow). There is no intrahepatic biliary dilatation. The gallbladder appears contracted (arrow). These findings are consistent with choledocholithiasis resulting in early or incomplete biliary obstruction.

Patient underwent endoscopic retrograde stone extraction with sphincterotomy. Injection of the common bile duct during the procedure showed a filling defect (arrow) corresponding to the calculus in the distal common bile duct.

Diagnosis

Choledocholithiasis

Discussion

Choledocholithiasis results from a gallstone that enters the common bile duct from the cystic duct or by erosion. Primary common duct stone arising in the intrahepatic or extrahepatic biliary tree is unusual. Choledocholithiasis in patients who have undergone cholecystectomy usually represents retained stones that were not identified at the time of surgery. About 75% of CBD stones can be delineated by ultrasound although detection will be limited in absence of bile duct dilatation. When ultrasonographic evaluation of distal common bile duct is limited by gas or particulate material in the adjacent duodenum, a CT scan or a cholangiogram can aid in establishing the definitive diagnosis.

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