Hepatolithiasis: A Cause for Persistent Abdominal Pain That Escaped MRCP

Abstract

Introduction: We report a case of a 37-year-old female with a past medical history of open cholecystectomy in 2004, ERCP with drain placement for biliary stones in 2005, and hepaticojejunostomy via Roux-en-Y for a severely strictured common bile duct in 2006, who presented to the ED with a 2-day history of right upper quadrant abdominal pain. Her recurrent chronic pain that predated surgery had recently worsened. Her symptoms were worse with deep inspiration and were associated with nausea and non-bloody emesis, though she denied fevers, dark colored urine, acholic stools, or changes in bowel habits. On exam, she was hemodynamically stable with right upper quadrant tenderness, hepatomegaly, and a positive Murphy’s sign. Laboratory investigation demonstrated normal AST, ALT, ALP, and bilirubin levels. Initial imaging with ultrasound and CT scan revealed distended intrahepatic biliary ducts in the right lobe without an identifiable cause. Upper endoscopy showed a normal esophagus, stomach, and duodenum; further evaluation with ERCP was limited due to her prior hepaticojejunostomy. Her pain continued to progressively worsen. Due to persistent progressive pain, MRCP was performed with findings of right hepatic lobe intrahepatic ductal dilatation, right lobe atrophy, and left lobe hypertrophy, without evidence of filling defect, mass, or stricture. Despite the negative MRCP, the patient’s persistent symptoms lead to further investigation with an IR guided percutanous cholangiogram. This revealed dilated right hepatic ducts were multiple filling defects consistent with hepatolithiasis. An internal/external biliary drain was placed for decompression. Due to the persistence of the intrahepatic stones, the patient was scheduled for biliary endoscopy with lithotripsy. At 2-week follow-up, after the lithotripsy, the patient was pain free. This case illustrates a relatively rare cause of a common complaint: hepatolithiasis causing right upper quadrant abdominal pain. While the established sensitivities and specificities for MRCP detecting hepatolithiasis and biliary strictures are 97% and 99% respectively, the identification of hepatic stones on percutanous cholangiogram in this patient illustrates the importance of clinical judgment over investigative results in pursuing further management, especially in patients with ongoing symptoms of unclear etiology and a complex surgical history.