Common Bile Duct Calculi Research Articles

Correlation and Diagnostic Agreement Between Ultrasonography and MRCP in Evaluating Obstructive Jaundice: A Prospective Study

Background: Obstructive jaundice is a clinical condition characterized by the yellow discoloration of the skin, sclera, and mucous membranes due to elevated bilirubin levels caused by bile flow obstruction. Accurate diagnosis of the obstruction's cause and site is essential for effective management. Ultrasonography (USG) is commonly used for initial screening, but it has limitations, especially in visualizing the distal common bile duct (CBD). Magnetic resonance cholangiopancreatography (MRCP) has emerged as a superior, non-invasive imaging modality with higher accuracy in evaluating biliary obstructions. Objective: To evaluate the correlation and agreement between USG and MRCP findings in patients with obstructive jaundice and to determine the diagnostic accuracy of each modality in detecting the level and cause of biliary obstruction. Methods: This prospective cohort study was conducted over six months at a tertiary care hospital in Rawalpindi. A total of 32 patients with clinical suspicion of obstructive jaundice were included. Each patient underwent both USG and MRCP. USG was performed using a GE Logiq-e machine, followed by MRCP on a Philips Achieva 1.5 Tesla MRI scanner. Data were analyzed using SPSS version 25. Pearson's correlation coefficient and kappa statistics were used to assess the correlation and agreement between the two modalities. The diagnostic accuracy of USG and MRCP was compared based on the detection of the level of obstruction and the identification of benign and malignant etiologies. Results: The mean age of the patients was 59.53 ± 13.41 years, with 65.6% being male. MRCP showed a diagnostic accuracy of 97.2% compared to 78.1% for USG. MRCP detected distal CBD calculi with 100% accuracy, while USG missed these in 11 cases. A positive correlation was found between USG and MRCP in detecting the site of obstruction (r = 0.48, p = 0.005), the porta hepatis as the site of obstruction (r = 0.47, p = 0.006), and the ampulla as the site of obstruction (r = 0.47, p = 0.006). However, the correlation for benign etiologies was weak (r = 0.094, p = 0.607), and for malignant etiologies, it was moderate (r = 0.31, p = 0.08). Conclusion: MRCP demonstrated superior diagnostic accuracy compared to USG in evaluating patients with obstructive jaundice, particularly in detecting distal CBD calculi and malignant lesions. While USG remains useful as an initial screening tool, MRCP should be considered the preferred imaging modality when detailed evaluation is required.

Pragmatic algorithm for management of common bile duct calculi in resource-limited settings in India.

Endoscopic retrograde cholangiopancreatography (ERCP) facilitates the removal of common bile duct (CBD) calculi by endoscopy. When ERCP fails, exploration of CBD is required for the clearance of CBD calculi. The optimum way for the exploration of CBD is by choledochoscopy. Dedicated flexible or rigid choledochoscopes are expensive and available only in few places in India. Since 1991, we subjected patients with suspected CBD calculi to ERCP, followed by laparoscopic cholecystectomy (LC). Patients in whom ERCP failed to clear CBD were subjected to open exploration of CBD using any easily available, suitable, straight rigid scope for choledochoscopy. Since March 1991, out of 8866 patients with cholelithiasis, 862 underwent ERCP. Ninety-six patients in whom ERCP failed to clear CBD underwent open exploration of CBD. In each case of exploration of CBD, choledochoscopy was performed using a straight rigid scope, either a cystoscope, paediatric cystoscope, hysteroscope or 5-mm laparoscopy telescope with a 5-mm cannula. The CBD clearance was complete in 95 patients, and one patient had an impacted calculus at the ampulla. CBD explorations were followed by choledochoduodenostomy, T-tube placement or suturing of choledochotomy. No residual calculi were observed after such exploration. From our results, we advocate the following algorithm for CBD calculi in resource-limited settings. Subject patients with CBD calculi to ERCP followed by LC. In case of failed ERCP, open exploration of CBD with choledochoscopy using any suitable rigid scope. Dedicated flexible or rigid choledochoscope is not essential. This approach is cost-effective and successful.

The use of indocyanine green and near-infrared imaging in laparoscopic completion cholecystectomy for the management of stump cholecystitis: A case series.

Stump cholecystitis is managed by performing a completion cholecystectomy, which can be done either laparoscopically or by an open method. The use of indocyanine green (ICG) is known to improve the identification of the biliary tree anatomy, facilitating Calot's triangle dissection and shortening surgery, thereby reducing the risk of bile duct injuries and making laparoscopic cholecystectomy safer. A retrospective analysis was performed of prospectively collected data from 15 patients at our institution from March 2016 to March 2021. Magnetic resonance cholangiopancreatography was performed in all 15 cases, showing remnant gall bladder in all cases with calculi within. Four cases had a dilated common bile duct (CBD) with CBD calculi. Endoscopic retrograde cholangiopancreatography (ERCP) and stone removal followed by CBD stenting were performed in the four patients with CBD calculi. These four cases were scheduled for surgery 4 weeks post-ERCP. All 15 patients underwent laparoscopic completion cholecystectomy. The mean operating time was 80 min. The post-operative period of all cases was uneventful, and the patients were discharged on post-operative day 2 or day 3. All patients remained asymptomatic during 1-5 years of follow-up. Laparoscopic completion cholecystectomy was performed safely in cases of stump cholecystitis and resulted in symptom relief during short-term follow-up. The use of ICG and near-infrared imaging in such cases helps identify the biliary anatomy, may contribute to the safety of laparoscopic completion cholecystectomy and might reduce the duration of surgery.

Post-ERCP acute infected necrotising pancreatitis in a patient with Cushing’s disease

This report discusses the case of patient KT, who suffered from acute necrotising pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP) for treatment of common bile duct (CBD) calculi. After a summary of KT’s complex medical history, the epidemiology and pathophysiology of post-ERCP pancreatitis (PEP) are discussed. Finally, recent research on treatment of severe necrotising pancreatitis is reviewed, focussing on strategies to reduce morbidity and mortality from this devastating complication of a common procedure like ERCP.

DOUBLE COMMON BILE DUCT ASSOCIATED WITH PANCREATIC DIVISUM: A CASE REPORT

Double common bile duct type I is a rare anomaly. Moreover, the association of double common bile duct and Pancreatic divisum is an even less common malformation. We reported a case of a combined double common bile duct type I and pancreatic divisum presented after complicated with a large common bile duct calculus. Classification and investigations for the double common bile duct are briefly discussed.

Effect of sphincter of Oddi dysfunction on the abundance of biliary microbiota (biliary microecology) in patients with common bile duct stones.

Biliary calculi, a common benign disease of the gastrointestinal tract, are affected by multiple factors, including diet, lifestyle, living environment, and personal and genetic background. Its occurrence is believed to be related to a change in biliary microbiota. Approximately 10%-20% of symptomatic patients with cholecystolithiasis have choledocholithiasis, resulting in infection, abdominal pain, jaundice, and biliary pancreatitis. This study aimed to determine whether a dysfunction in the sphincter of Oddi, which controls the outflow of bile and separates the bile duct from the intestine, leads to a change in biliary microbiota and the occurrence of biliary calculi. Forty patients with cholecystolithiasis and choledocholithiasis were prospectively recruited. Bile specimens were obtained, and biliary pressure was measured during and after surgery. The collected specimens were analyzed with 16S rRNA gene to characterize the biliary microbiota. The risk factors of common bile duct calculi were analyzed numerically combined with the pressure in the sphincter of Oddi. Different biliary microbiota were found in all cases. Patients with sphincter of Oddi dysfunction had significantly increased biliary microbiota as well as significantly higher level of systemic inflammation than patients with normal sphincter of Oddi. The systemic inflammatory response of patients with sphincter of Oddi dysfunction is more severe, and their microbial community significantly differs from that of patients with normal sphincter of Oddi, which makes biliary tract infection more likely; furthermore, the biliary tract of patients with sphincter of Oddi dysfunction has more gallstone-related bacterial communities.

Relative contribution of susceptibility weighted imaging, compared to conventional MRI, in the detection of common bile-duct calculi.

PURPOSE We aimed to evaluate the relative contribution of susceptibility weighted imaging (SWI) in the detection of common bile-duct (CBD) stones in comparison to the conventional MRI protocol containing magnetic resonance cholangiopancreatography (MRCP), balanced turbo field echo (BTFE), and T2-weighted spin-echo imaging techniques. METHODS MRI data containing MRCP, BTFE, T2-weighted imaging, and abdominal SWI were independently evaluated by 2 sets of experienced radiologists in 44 patients with confirmed CBD stones. Endoscopic retrograde cholangiopancreatography, and endoscopic ultrasound where available, was used as the reference gold standard. Evaluation was performed for the visualization of CBD stones in each of the MRI techniques. Relative contribution of SWI was classified into one of four categories for each case: (1) no contribution to CBD stone visualization; (2) same as conventional techniques; (3) improved diagnostic confidence; and (4) critical for diagnosis. Stone size was also assessed. RESULTS Inter-rater agreement coefficient for CBD stone visualization was found to be "good" in MRCP (0.77), "very good" in SWI (0.94) and BTFE (0.84), and moderate in T2-weighted imaging (0.54). CBD stones were visualized with SWI in 86.4% and 82%, with MRCP in 70.5% and 70.5% cases, with BTFE in 73% and 61.4% cases, with T2-weighted imaging in 45.5% and 52.3% cases by reviewers 1 and 2, respectively. SWI did not contribute to CBD stone visualization in 2.3% (1/44); was the same as conventional techniques in 31.8% (14/44) cases; improved diagnostic confidence in 34.1%; and was critical for diagnosis in 20.5% cases. CONCLUSION SWI has the potential to serve as a strong adjunct to conventional MRI protocols used for CBD stone evaluation with very small scan-time penalty.

UNUSUAL CAUSE OF BILIARY OBSTRUCTION IN AN ASYMPTOMATIC PATIENT

Benign tumors arising from the extra hepatic biliary tree are very rare, and are reported to occupy 6% of all tumors of the bile ducts. In benign tumors, adenoma and papilloma are the most common ones. Adenomas of the extra hepatic biliary tree usually present clinically with features of obstructive jaundice or chronic right upper quadrant pain. Herein, we report a case of a 77-year-old woman with right lower limb weakness secondary to left subdural hemorrhage being diagnosed incidentally with extra and intrahepatic biliary obstruction secondary to distal common bile duct lesion on radiological examination. It was initially misinterpreted as a common bile duct calculus. This diagnosis was of utmost importance because of the malignant potential of these benign tumors. Our study sheds light on the common pitfall in radiological diagnosis in such case between calculus and mass lesion and how to avoid it.

Is It a Bird? Is It a Plane? It's a Tumour – Operative Transcystic Choledochoscopy for Differentiation of Biliary Duct Filling Defect and New Early Diagnosis of Insidious Pancreatic Adenocarcinoma

Background: Operative Transcystic Choledochoscopy (OTC) during Laparoscopic Cholecystectomy (LC) is a one-procedure solution for clearance of Common Bile Duct (CBD) calculi under vision and allows identification and biopsy of biliary neoplasms. Success and complication rates in high-volume centres are similar or superior to Endoscopic Retrograde Cholangiopancreatography (ERCP). Preference for ‘minimally-invasive’ techniques like ERCP has led to infrequent use and resultant deskilling. Its ongoing role is therefore currently unclear. Case: A well 65-year-old male with epigastric pain and raised lipase, and Computed Tomography (CT) showing cholelithiasis and ‘focal pancreatitis involving the uncinate process’, underwent LC for gallstone-induced pancreatitis 6 days after presentation. Pre-operative bilirubin was normal and ALKP (133 U/L) and GGT (270 U/L) newly raised. An oedematous stone-containing gallbladder and a distal CBD filling defect on Intraoperative Cholangiogram were found. OTC demonstrated a CBD wall growth but biopsy equipment was unavailable. No peritoneal or liver metastases were seen. Ca19.9 (588 kU/L) was elevated. Pancreas-protocol CT/MRI showed a 14x14mm ‘indeterminate abnormality’ in the head/uncinate process without vascular involvement, and staging CT was negative for metastases. Endoscopic Ultrasound-guided biopsy diagnosed pancreatic adenocarcinoma following non-diagnostic ERCP. A Whipple’s procedure was planned but later abandoned as liver metastases were confirmed on frozen section at staging laparoscopy. Discussion: Despite recent movement away from OT during LC, this study highlights its utility in early identification of insidious biliary neoplasmswith the first case of preliminary pancreatic adenocarcinoma diagnosed with OTC during LC in a non-obstructed patient.

Endoscopically non-removable stones of the common bile duct

To evaluate the effectiveness of long-term biliary stenting in the treatment of endoscopically intractable common bile duct stones. The study enrolled 247 patients with endoscopically non-removable bile duct calculi («difficult» choledocholithiasis) divided into two comparable groups. The main group included 129 patients who underwent biliary stenting with original stents with a nanocarbon inert coating (RF patent No. 84226), including those with inclusion of silver nanoclusters (RF patent No. 129397). The control group included 118 patients who underwent all methods of surgical treatment of choledocholithiasis, while biliary stents with original nanocarbon silver-containing inert coating were excluded. The vast majority of patients were women of advanced age (mean 66.8±4.7 and 66.3±5.6, max 89 and 90, min 32 and 37 years, respectively). In the control group, all patients underwent endoscopic transpapillary interventions as soon as possible. We could not extract common bile duct stones via endoscopic approach in 56.8% of cases. These patients underwent open or laparoscopic choledocholithotomy with lithoextraction. Complications occurred in 28.5% of cases. Mortality rate was 4.2%. Standard stenting of common bile duct was performed in 28.8% of cases. At the same time, stent dysfunction followed by relapse of obstructive jaundice occurred in 27.1% of patients within 3-3.5 months. Of these, 16 patients (13.5%) underwent stent removal and lithoextraction. Re-stenting was performed in 18 patients (15.3%). Moreover, shock wave lithotripsy with subsequent removal of common bile duct calculi was performed in 8 (6.8%) of these patients the next day. In the main group, original biliary plastic stents with nanocarbon silver-containing inert coating were implanted in all patients. Under permanent therapy with ursodeoxycholic acid drugs, we observed significant shrinkage of calculi to 11.8±1.8 mm and decrease in their density. This made it possible to carry out successful extraction of calculi in 81 patients (62.8%) after 6±0.3 months. Shock wave lithotripsy was performed in 36 (27.9%) cases. This procedure was successful and allowed final lithoextraction in 28 patients (21.7%). Re-stenting was performed in 15 (11.6%) cases, laparotomy - in 5 (3.9%) patients. Mortality rate was 0.78%. Our data allow us to discuss high efficiency of long-term bile duct stenting with plastic stents with nanocarbon silver-containing inert coating in complex treatment of choledocholithiasis. This approach ensures acceptable incidence of undesirable complications and mortality. This situation undoubtedly dictates the need for further larger prospective studies.

A case report of spontaneous biliary peritonitis with accessory liver lobe: rare presentation of a rare pathology

Spontaneous intrahepatic bile duct perforation with associated accessory liver lobe is an exceedingly rare condition with very few cases reported in the literature. Here we report a case of 76 years old man presenting with severe pain, abdominal distension since 3 days having jaundice and signs of peritonitis. Having undergone an exploratory laparotomy, 1 liter of bilious peritoneal fluid was seen with a perforation of left intra hepatic bile duct with a presence of an accessory lobe of liver. The gall bladder was contracted with multiple stones. Extrahepatic biliary duct was found normal intraoperatively. A cholecystectomy with resection of the accessory liver lobe was done. Post operatively patient had persistence of jaundice for which a magnetic resonance cholangiopancreatography was done, revealing a distal common bile duct calculus. Patient underwent endoscopic retrograde cholangiopancreatography with stone extraction on post operative day 10 relieving the symptoms. Patient is on regular follow up with no further complications. Awareness of such unusual occurrences is necessary for early diagnosis and instituting the appropriate treatment thereby reducing the mortality.

Diagnostic Accuracy of Magnetic Resonance Cholangiopancreatography (MRCP) In-Patients Undergoing Endoscopic Retrograde Cholangiopancreatography (ERCP) for Pancreaticobiliary Disorders

This is a prospective study done to compare the diagnostic accuracy of Magnetic Resonance Cholangiopancreatography (MRCP) in patients undergoing Endoscopic Retrograde Cholangiopancreatography (ERCP) for pancreaticobiliary disorders.Majority of the study participants were males (63.3%), while the rest 36.78% of them were females and periampullary carcinoma (11.7%) and common bile duct calculus (11.7%) are the common cause of obstruction found on MRCP followed by malignant stricture (10%). The extent of obstruction was determined in most of the study participants (91.7%) by MRCP while the rest 8.3% were not determined by MRCP. The Common bile duct calculus (11.7%) is the common cause of obstruction on ERCP followed by malignant stricture (10%) and Periampullary carcinoma (10%) and 20% of the patients were found to be normal in ERCP. Among them, 71.4 % did not show MRCP and the association was found to be significant. (p- Value < 0.00).

Long-term effects of endoscopic papillary large balloon dilation in patients with challenging bile duct calculi: A retrospective observational study.

Endoscopic papillary large balloon dilation (EPLBD) can be used to treat challenging common bile duct stones. No previous studies have reported intractable cases treated either by EPLBD or mechanical lithotripter use. We aimed to evaluate and compare the long-term effects of EPLBD with mechanical lithotripter use.This retrospective cohort study reviewed data from 153 patients admitted to the Eastern Chiba Medical Center from April 2014 to March 2020, presenting with common bile duct calculi that could not be removed using a basket or balloon catheter. Patients were divided into groups depending on whether the treatment was performed using a mechanical lithotripter or EPLBD. The primary outcome was the recurrence rate of common bile duct calculi, and the secondary outcome was the rate of postoperative adverse events. The Wilcoxon test was used to compare the 2 groups. Statistical significance was set at P < .05.The median age of patients included in the lithotripter and EPLBD groups were 73 years and 83 years, respectively (P = .006), while the sex ratio (male:female) in the groups was 18:13 and 55:67, respectively. The EPLBD group showed a statistically larger median bile duct diameter (13 mm [range: 8–24 mm] vs 11 mm [range: 5–16 mm]; P < .001), larger maximal calculus diameter (median, 13.5 mm [range: 8–25 mm] vs 11 mm [range: 7–16 mm]; P < .001), and shorter median cumulative treatment time after reaching the duodenal papilla (35.5 minutes [range: 10–176 minutes] vs 47 minutes [range: 22–321 minutes]; P = .026) in comparison to the lithotripter group. There was no significant difference in the rate of adverse events between the EPLBD and the mechanical lithotripter groups. The recurrence rate was significantly lower (P = .014) in the EPLBD group.EPLBD increases therapeutic efficacy and reduces treatment duration for patients in whom calculus removal is difficult, without increasing the frequency of adverse events. No serious adverse events were observed. Additionally, EPLBD appears to reduce the risk of long-term recurrence. Future studies are needed to evaluate long-term outcomes in younger patients.

A case report of spontaneous passage of large (&gt;1.5 cm) common bile duct calculi (4 in number) through faeces

Gallbladder (GB) stones are commonly associated with common bile duct stones (CBDS). While they may remain asymptomatic, some may present with symptoms like biliary colic, jaundice and cholecystitis. Most of these stones in the CBD, if small, pass through faeces. Passing larger stones through faeces is relatively rare and if it does occur, is usually associated with fatal complications like acute pancreatitis. The authors reported a case wherein symptomatic large CBD stones were spontaneously passed through faeces and the patient was relieved of the symptoms and did not suffer any further complications. Choledocholithiasis is usually managed by endoscopic retrograde cholangiopancreatography or by laparoscopic or open choledocholithotomy. Spontaneous passage of small CBD and GB calculi through faeces although common is associated often with the development of pancreatitis. Passage of large CBD calculi (size &gt;1.5 cm) through faeces is rarely seen.

Management of Obscurely Dilated Common Bile Duct with Normal Liver Function Tests: A Pragmatic Approach.

Dilated common bile duct (CBD) (8-15mm) with normal liver function tests is seen not infrequently, while management of such patients is ambiguous. We propose a treatment algorithm for this cohort of patients after observing them over a period of 8years. Seventy-eight such patients were managed from 2009 to 2017 and categorized as: Group A-dilated CBD with post-cholecystectomy status (n = 15); B-dilated CBD with cholelithiasis (n = 34); C-dilated CBD without cholelithiasis (n = 16); D-dilated CBD with no cause identified and underwent CBD excision (n = 13). Causes for CBD dilatation were evaluated. The outcome of patients in Group B + C without any cause (n = 33) was compared with Group D. Median age, CBD diameter, bilirubin and alkaline phosphatase were 51years (13-79), 10mm (8-20), 0.6mg/dl (0.2-2.5) and 126IU (60-214), respectively. Group-A patients who did not manifest any cause of CBD dilatation were managed conservatively. The aetiology was identified in 17/50 patients in Group B & C [acute pancreatitis (n = 6), passed CBD calculi (n = 3), perivaterian diverticulum (n = 3), viral aetiology (n = 4) and tumour (n-1)]. In Group-C, 7 patients with no obvious cause underwent endoscopic sphincterotomy, pancreatoduodenectomy (n = 1), and the rest were managed conservatively (n = 8). There was no significant difference in the complication between Group B + C (without any cause) and Group D (3/33 vs. 1/13; p = 0.58) at a median follow-up of 72months (30-90). Dilated CBD with normal LFT's without apparent cause is mostly benign and of no consequence. Excision of the CBD is not required for most of these patients.

Assessing Patient Preoperatively and Role in Decreasing Risks on Patients and Preventing Post-Operative Complications for Cholecystectomy

Background: Laparoscopic cholecystectomy has many difficulties which include port Insertion, Dissectionof the Calot’s Triangle , Grasping of the Gallbladder , Wall thickness, Adhesion and extraction of theGallbladder. Aim of the Study: To predict how difficult cholecystectomy will be from assessing the patientpreoperatively which, in turn, help in decreasing the risks on the patients and preventing post-operativecomplications. Patients and Methods: A prospective study conducted in the department of General Surgeryat Al-Ramadi Teaching Hospital for the period of nine months from 15th of May 2018 till the 15th of February2019. It included 60 patients, all of them were undergone laparoscopic cholecystectomy for Gallstone. Patientswith common bile duct calculus, dilated common bile duct, current attack of acute cholecystitis, those withabsolute contraindications to laparoscopic cholecystectomy, The data were collected prospectively to predictthe significance of association with patients’ characteristics. The time of operation was calculated from thefirst port site incision until the last port closure. All the intra operative events were recorded. Conversionsto open cholecystectomy were done by median or subcostal laparotomy according to the surgeon’s decisionand each patient’s condition. Results: In this study, the highest proportion of operations was categorizedas easy (58.3%), 28.3% of operations were considered difficult and 13.3% of them were very difficult. Asignificant association (P &lt; 0.05) between operation difficulty and all of the following characteristics: Aging,obesity, history of previous biliary hospitalization, thickened bladder wall, pericholecystic collection, andlarge stones. Conclusions: The difficult laparoscopic cholecystectomy can be predicted preoperativelybased on number of factors, like: obesity, previous biliary admission, gall bladder wall thickness, ultrasoundfindings (stone size and pericholecystic fluid) and aging process, evaluating of such factors minimize thecomplications of laparoscopic cholecystectomy and conversion to the open procedure.

Natural History of Retained Common Bile Duct Calculi Noted on Intra-Operative Cholangiography

Introduction: Incidental common bile duct (CBD) calculi is found in approximately 11% of routine intra-operative cholangiograms (IOC) during laparoscopic cholecystectomy (LC). An uncertain proportion of these may remain asymptomatic or pass spontaneously, and therefore not require invasive intervention.

Management of common bile duct calculi in a tertiary care hospital in North East India

Background: Common bile duct calculi are frequently encountered in patients with cholelithiasis. Treatment ranges from endoscopic retrograde cholangiopancreatography (ERCP) to various surgical treatment modalities done either by laparoscopic or open techniques.Methods: This was a retrospective cross-sectional study carried out in General Surgery department of NEIGRIHMS Hospital from April 2014 to March 2020. Patients attending the hospital with choledocholithiasis during the time period have been included in the study.Results: A total of 82 patients were included in the study. The prevalence of common bile duct (CBD) calculi in patients attending NEIGRIHMS Hospital with symptomatic gallstone diseases was 5.16%. Treatments ranged from primary CBD closure or T-tube drainage after CBD exploration either by laparoscopic techniques, choledocho-duodenostomy and ERCP. Bile peritonitis in 9 patients and retained stone were observed in some patients who were managed accordingly. No mortality was seen in any patient.Conclusions: The number of patients with CBD calculi and symptomatic gallstone disease attending NEIGRIHMS Hospital is less and standard of care is provided to the patients with acceptable morbidity and mortality.

Acute gallbladder torsion: computed tomography and magnetic resonance imaging findings.

An 88‐year‐old female presented to emergency with a 3‐h history of severe, colicky epigastric and right upper quadrant pain radiating to the lower abdomen with associated nausea and vomiting. Initial observations revealed normal temperature and heart rate but hypertension with a systolic blood pressure of 180 mmHg. On examination the abdomen was soft and non‐distended with a tender, palpable mass in the right upper quadrant. Blood tests showed an elevated white cell count (14.2 × 109/L), and mildly deranged liver function tests with a normal bilirubin (18 μmol/L). Abdominal computed tomography scanning was requested, which revealed a markedly distended gallbladder with moderate pericholecystic fluid but no cholelithiasis. The intra‐ and extrahepatic biliary tree was dilated with the common bile duct measuring 10 mm in the pancreatic head but no obstructing lesion or stone was visible. Initial management was commenced, including analgesia, intravenous fluid resuscitation and broad spectrum intravenous antibiotics. Due to the imaging findings suggesting distal biliary tree obstruction of unclear aetiology, contrast enhanced magnetic resonance imaging (MRI) scanning was performed prior to cholecystectomy. MRI findings consisted of a distended and thick‐walled gallbladder with reduced signal along the posterior gallbladder wall and a 2‐mm calculus at the gallbladder neck. Gallbladder orientation was abnormal with the fundus situated infero‐medial to Hartmann's pouch. Biliary tree and pancreatic ductal dilatation to the ampullary level was again observed (13 mm proximal common bile duct [CBD]) but no obstructing common bile duct calculus or peri‐ampullary mass was identified (Fig. 1). At laparoscopic cholecystectomy a gallbladder torsion was observed with associated haemorrhagic necrosis but no gallbladder perforation (Fig. 2). Following decompression and de‐torsion, surgery proceeded uneventfully, histological examination was consistent with acute gangrenous cholecystitis with no cholelithiasis. The patient recovered well from surgery and was discharged home on post‐operative day 2.

Incidentally Detected Residual Gallbladder Calculi by Computed Tomography in Acute Pancreatitis. Case Report

Calculi in the gallbladder or cystic duct remnant account for 0.3 to 2.5% of cases of post-cholecystectomy syndrome and must be considered in any patient who has undergone “difficult” cholecystectomy. We present an interesting case of a 62-year-old male, diagnosed to have moderately severe acute biliary pancreatitis, 4 years past laparoscopic converted to open cholecystectomy (LCOC). On evaluation with contrast computed tomography (CT) of the abdomen, changes of acute pancreatitis, along with a remnant gallbladder containing radiopaque calculi, were identified. The patient subsequently was managed successfully with completion cholecystectomy with common bile duct (CBD) exploration and T-tube drainage (for CBD calculi). Hence, differential diagnosis of residual gallbladder calculi (although rare) should be kept in a patient with acute biliary pancreatitis, following LCOC for a “difficult” gallbladder.