Choledocholithiasis

Abstract

A 49-year-old woman was admitted to our hospital in June, 2003, with abdominal pain, jaundice, altered mental status, and hypotension. She had right upper quadrant tenderness but no signs of peritoneal irritation. Blood tests showed leucocytosis, hyperbilirubinaemia, and increased concentrations of alkaline phosphatase. Plain abdominal radiographs showed calcified stones in her gallbladder and common bile duct (figure). We started fluid resuscitation and broad-spectrum antibiotics. An endoscopic retrograde cholangiography with sphincterotomy, and bile duct clearance was done within 24 h of admission. 7 days later a cholecystectomy was done, and the patient had an uneventful postoperative course. Acute cholangitis occurs as a result of bacterial infection superimposed on obstruction of the biliary tree. 50–70% of patients present with all three classical features of Charcot's triad (jaundice, right upper quadrant pain, and fever). Some patients are also confused and hypotensive—Reynold's pentad. Nearly 20% of cholesterol stones and 80% of pigment stones contain enough calcium to be visible on plain films of the abdomen. All patients with acute cholangitis require biliary drainage. A 49-year-old woman was admitted to our hospital in June, 2003, with abdominal pain, jaundice, altered mental status, and hypotension. She had right upper quadrant tenderness but no signs of peritoneal irritation. Blood tests showed leucocytosis, hyperbilirubinaemia, and increased concentrations of alkaline phosphatase. Plain abdominal radiographs showed calcified stones in her gallbladder and common bile duct (figure). We started fluid resuscitation and broad-spectrum antibiotics. An endoscopic retrograde cholangiography with sphincterotomy, and bile duct clearance was done within 24 h of admission. 7 days later a cholecystectomy was done, and the patient had an uneventful postoperative course. Acute cholangitis occurs as a result of bacterial infection superimposed on obstruction of the biliary tree. 50–70% of patients present with all three classical features of Charcot's triad (jaundice, right upper quadrant pain, and fever). Some patients are also confused and hypotensive—Reynold's pentad. Nearly 20% of cholesterol stones and 80% of pigment stones contain enough calcium to be visible on plain films of the abdomen. All patients with acute cholangitis require biliary drainage.