Talks
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Resident
Discipline/Specialty (Author 1)
Internal Medicine
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Resident
Discipline/Specialty (Author 2)
Internal Medicine
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Resident
Discipline/Specialty (Author 3)
Internal Medicine
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Medical Student
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Patient Care
Abstract
Background: Common bile duct dilation is expected in certain healthy populations with specific factors like age or post procedure status. When a size larger than expected is found in an acute setting further investigation is required. In the setting of acute abdominal pain in a patient with past medical history of cholelithiasis, the study protocol for patients with more than expected enlarged common bile duct and no apparently underlying disease in the biliary tree is not well elucidated.
Case: A 68-year-old female with past medical history but not limited to cholelithiasis, hypertension, type 2 diabetes mellitus, end stage renal disease on hemodialysis presented with severe right and left upper quadrant pain, described as colic, without increasing or decreasing factors. The patient initially presented to the gastroenterologist clinic for this pain when abdominal ultrasound revealed cholelithiasis with common bile duct dilation warranting hospital referral for calculous cholecystitis.
Upon admission, the patient continued with severe upper right and left quadrant abdominal pain, liver function tests, amylase and lipase were unremarkable, CT of the abdomen revealed cholelithiasis and a 4.2 cm duodenal diverticulum. Follow-up right upper quadrant ultrasound revealed cholelithiasis, dilated common bile duct at 1.2cm without gallbladder wall thickening. After inpatient GI evaluation, endoscopy identified a large periampullary diverticula full of food and without discernible stones meanwhile endoscopic ultrasound suspected artifact due to diverticular effects and distended gallbladder was seen with large stone. ERCP was not performed. Robotic assisted cholecystectomy was performed without complication. Gallbladder pathology reported acute on chronic cholecystitis with cholelithiasis and metaplastic epithelial changes.
Conclusion: In evaluating the necessity of endoscopic retrograde cholangiopancreatography (ERCP), appropriate imaging is critical. Preoperative ERCP is preferred when a stone is identified in the distal bile duct and/or laboratory study suggests obstruction of the common bile duct, as gallbladder removal may risk dislodging biliary clips. The imaging modalities under consideration are CT scan and abdominal ultrasound, when in doubt magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound (EUS) are considerable options. Research indicates that EUS is a superior and more cost-effective option compared to MRCP. Additionally, magnetic resonance imaging (MRI) can be problematic due to its limitations in detecting diverticula. EUS emerges as a particularly advantageous choice for patients with unclear diagnosis being less expensive than MRCP and with less risk for adverse events than sending the patient into surgery with a dilated common bile duct and an unclear diagnosis.
Presentation Type
Talk
Recommended Citation
Trujillo, Mario A.; Peynado, Mathew R.; Siddiqui, Muhammad Ali; and Ackerman, Laura P., "Unexpected Biliary Duct Dilation, A Wise Decision-Making Case." (2024). Research Colloquium. 18.
https://scholarworks.utrgv.edu/colloquium/2024/talks/18
Included in
Digestive System Diseases Commons, Gastroenterology Commons, Internal Medicine Commons, Medical Anatomy Commons
Unexpected Biliary Duct Dilation, A Wise Decision-Making Case.
Background: Common bile duct dilation is expected in certain healthy populations with specific factors like age or post procedure status. When a size larger than expected is found in an acute setting further investigation is required. In the setting of acute abdominal pain in a patient with past medical history of cholelithiasis, the study protocol for patients with more than expected enlarged common bile duct and no apparently underlying disease in the biliary tree is not well elucidated.
Case: A 68-year-old female with past medical history but not limited to cholelithiasis, hypertension, type 2 diabetes mellitus, end stage renal disease on hemodialysis presented with severe right and left upper quadrant pain, described as colic, without increasing or decreasing factors. The patient initially presented to the gastroenterologist clinic for this pain when abdominal ultrasound revealed cholelithiasis with common bile duct dilation warranting hospital referral for calculous cholecystitis.
Upon admission, the patient continued with severe upper right and left quadrant abdominal pain, liver function tests, amylase and lipase were unremarkable, CT of the abdomen revealed cholelithiasis and a 4.2 cm duodenal diverticulum. Follow-up right upper quadrant ultrasound revealed cholelithiasis, dilated common bile duct at 1.2cm without gallbladder wall thickening. After inpatient GI evaluation, endoscopy identified a large periampullary diverticula full of food and without discernible stones meanwhile endoscopic ultrasound suspected artifact due to diverticular effects and distended gallbladder was seen with large stone. ERCP was not performed. Robotic assisted cholecystectomy was performed without complication. Gallbladder pathology reported acute on chronic cholecystitis with cholelithiasis and metaplastic epithelial changes.
Conclusion: In evaluating the necessity of endoscopic retrograde cholangiopancreatography (ERCP), appropriate imaging is critical. Preoperative ERCP is preferred when a stone is identified in the distal bile duct and/or laboratory study suggests obstruction of the common bile duct, as gallbladder removal may risk dislodging biliary clips. The imaging modalities under consideration are CT scan and abdominal ultrasound, when in doubt magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound (EUS) are considerable options. Research indicates that EUS is a superior and more cost-effective option compared to MRCP. Additionally, magnetic resonance imaging (MRI) can be problematic due to its limitations in detecting diverticula. EUS emerges as a particularly advantageous choice for patients with unclear diagnosis being less expensive than MRCP and with less risk for adverse events than sending the patient into surgery with a dilated common bile duct and an unclear diagnosis.