Long term opiate abuse and common biliary duct dilatation

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Background: Acalculous common bile duct dilation secondary to chronic opioid use is a rare event that has largely only been reported in case reports. Although it is typically discovered incidentally in asymptomatic patients, it should not be ignored due to overlap with more serious hepatobiliary pathology. This especially true given the increasing use of methadone and increased risk of complications in the patients receiving this medication. Methods: Learning objectives: 1. Showcase the typical risk factors and clinical presentation of a patient with methadone-induced common bile duct dilation 2. Discuss the imaging modalities used to confirm diagnosis 3. Demonstrate the clinical importance of this finding and how it may impact future management of patients. Results: 64-year-old African American male with past medical history of HIV/AIDS hepatitis C, chronic obstructive pulmonary disease, chronic kidney disease and opioid dependence was admitted for COPD exacerbation and respiratory failure. The patient’s hospital course was complicated by sepsis. Incidentally, common bile duct dilation of 1.1 cm was discovered on CT thorax. Despite no patient complaints of nausea, vomiting, or right upper quadrant pain, the degree of dilation warranted further investigation. Laboratory studies revealed a normal bilirubin level and only mildly elevated liver enzymes. MRCP revealed bile duct dilation extending from the common bile duct into the intrahepatic ducts. Despite the extent of dilation, the patient remained asymptomatic throughout the hospital course. Conclusion: As evidenced by this case, common bile duct dilation due to chronic opioid use is typically a benign finding. However, due to the increased frequency of methadone use in patients with Hepatitis C, a diagnostic work-up is still required to rule out hepatocellular carcinoma and cirrhosis. Imaging options include endoscopic ultrasound, Endoscopic retrograde cholangiopancreatography, and Magnetic resonance cholangiopancreatography. Once a diagnosis is made, clinicians should be aware of possible complications which most notably include cholangitis secondary to biliary stasis, impaired liver function due to backflow of bile, and pancreatitis. The frequency of complications is not widely studied, but may be warranted as the use of methadone increases.