Impacted Common Bile Duct Stone

Abstract

Purpose: Case Presentation: A 29 year old white female, three weeks postpartum presented to the emergency room with intermittent right upper quadrant (RUQ) abdominal pain, which she rated as 5/10. She first noticed the pain her last trimester of pregnancy but had worsened over the last 3 weeks. She described the pain as colicky, intermittent and occurs mostly post prandial. Her past medical history, surgical history and family history were unremarkable. She denied any prescription or over the counter medications. The patient was seen in the morning for consultation. She was in no acute distress, resting comfortably and abdominal examination was benign. There were no clinical signs of cholangitis. Alkaline phosphatase was 208 units/L, AST was 245 units/L, ALT was 203 units/L and total bilirubin 0.7 mg/dL. Abdominal ultrasound revealed cholelithiasis and choledocholithiasis with the common bile duct dilated to 11 mm. Endoscopic Retrograde Cholangiopancreatography (ERCP) was decided to be the next appropriate step. In the pre-operative area of the endoscopy unit, the patient developed sudden onset of RUQ abdominal pain, which she rated as 10/10. She was immediately taken to the endoscopy suite in which an ERCP was performed. An impacted stone was seen at the ampulla and was the likely cause of her acute onset of pain. See Figure 1. A needle-knife sphincterotomy (NKS) was performed with immediate passage of the stone and sludge. Discussion: NKS is frequently used when the endoscopist encounters a difficult common bile duct (CBD) cannulation. Using the needle-knife, a cut is made in the 11 o'clock direction to help open the biliary orifice and to avoid any damage to the pancreatic duct. In cases of impacted stone in which cannulation of the CBD may not even be an option, a NKS is commonly used. After the NKS was performed in this patient, the sphincterotomy was extended and the CBD underwent balloon sweep which removed sludge and stone fragments. The patient's laboratory values returned to normal on the following day. She underwent a laparoscopic cholecystectomy as an outpatient.Figure