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Single gigantic calculus of common bile duct and multiple hepatolithiasis
The American Journal of Surgery (2011) 202, e38 – e40
Clinical Images
Single gigantic calculus of common bile duct and multiple hepatolithiasis Yiping Mou, M.D., F.A.C.S., Huijiang Zhou, M.D.*, Bin Xu, M.D. Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China KEYWORDS: Choledocholithiasis; Hepatolithiasis; Hepatectomy; Biliary surgery
Abstract. Choledocholithiasis is a very common surgical disease worldwide. Reports of a single calculus of the common bile duct ⬎10 cm are very rare. The authors present a case of a single gigantic calculus in the common bile duct with multiple stones distributing in the left intrahepatic ducts. The patient was treated with left hemihepatectomy combined with Roux-en-Y hepaticojejunostomy, and the postoperative course was uneventful. Left hemihepatectomy combined with Roux-en-Y hepaticojejunostomy was the optimal treatment for this patient, with a satisfactory outcome. © 2011 Elsevier Inc. All rights reserved.
Common bile duct stones and hepatolithiasis are prevalent in developing countries in East Asia, especially in China, and recently have also been encountered with increasing frequency in some Western countries, such as the United States.1,2 Choledocholithiasis and hepatolithiasis are of special clinical significance because of their close association with biliary colic, acute pancreatitis, and cholangitis and can even lead to cholangiocarcinoma due to repeated episodes of cholangitis.3–5 In this report, we present a rare case of a single gigantic calculus in the common bile duct along with multiple calculi dispersed in left intrahepatic ducts.
Case report A 51-year-old woman presented with a 1-year history of diabetes mellitus with chronic intermittent vague pain in the right upper quadrant without fever or icteric sclera for ⬎18 years. On admission, the physical examination revealed a firm, palpable lump approximately 8 cm in diameter under * Corresponding author. Tel.: 86-571-86006291; fax: 86-571-86060497. E-mail address: [email protected] Manuscript received April 12, 2010; revised manuscript July 24, 2010
0002-9610/$ - see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2010.07.043
her xiphoid process, without tenderness. Routine laboratory analysis showed slight elevations in serum alkaline phosphatase level (125 U/L; normal range, 30 –110 U/L) and ␥-glutamyltransferase levels (99 U/L; normal range, 5–50 U/L), with normal levels of serum aspartate amino transferase (23.3 U/L), alanine aminotransferase (29 U/L), and total bilirubin (.45 mg/dL). Computed tomography and magnetic resonance imaging of the abdomen revealed multiple intrahepatic duct calculi with severe atrophy of the left liver lobe and segment V (Fig. 1A), as well as a single gigantic calculus approximately 12.5 cm in length in the common bile duct (Figs. 1B and 2). The patient was treated with left hemihepatectomy combined with resection of segment V and the common bile duct and Roux-en-Y hepaticojejunostomy. Postoperative pathologic findings showed multiple intrahepatic bile duct stones with tiny abscess formation. Chronic cholangitis of the common bile duct was also indicated. The postoperative course was uneventful, and the patient was discharged 12 days after the operation in good condition. Four months later, the patient returned for a checkup, without any complaints of fever or pain. Reexamination on computed tomography indicated mild left hepatic inflammatory effusion and biliary pneumatosis without postoperative residual stones (Fig. 3).
Y. Mou et al.
Single gigantic choledocholithiasis and multiple hepatolithiasis
e39
Comments Choledocholithiasis and hepatolithiasis are common surgical diseases worldwide and should be considered in patients with elevated liver function studies, jaundice, acute pancreatitis, radiologic signs of dilated intrahepatic or extrahepatic ducts, or ultrasound evidence of common bile duct stones. In the past 2 decades, imaging technology has markedly improved. In combination with clinical symptoms and laboratory abnormalities, physicians are able to think of specific clinical questions or possible diagnoses. Specifically, ultrasound examination has become an initial step in management, allowing physicians to identify patients who have potential biliary obstruction diseases. Computed tomographic scans are routinely performed, with sensitivity of 65% to 93% and specificity of 84% to 100%.6,7 Better options include magnetic resonance imaging and endoscopic ultrasound, with sensitivity and specificity ⬎ 90%.6 – 8 Abdominal computed tomography of the patient
Figure 2 Magnetic resonance imaging indicated a single gigantic stone in the common bile duct (white arrows). Inset showing this single gigantic calculus removed from common bile duct measuring 12.5 ⫻ 6.5 ⫻ 5.0 cm. G ⫽ gallbladder; L ⫽ liver.
showed multiple intrahepatic ducts calculi with severe atrophy of left liver lobe and segment V. Depending on the location, size, and quantity of calculi, or on whether there is any complication of severe bile duct infection, appropriate surgical procedures should be considered, such as endoscopic retrograde cholangiopancreatography, and sphincterotomy, laparoscopic or open common bile duct exploration or combined with hepatectomy. The main purpose of these surgical treatments is to remove inflammatory tissue and calculi, relieve ductal stenosis, and improve biliary drainage.9
Figure 1 (A) Contrast-enhanced computed tomography showed multiple intrahepatic duct calculi with severe atrophy of the left liver lobe and segment V (black arrows). (B) A single gigantic stone in the common bile duct (white arrows) and some crevices of this gigantic calculus (black arrows). G ⫽ gallbladder; L ⫽ liver.
Figure 3 Reexamination on computed tomography indicated mild left hepatic inflammatory effusion (white arrow) and biliary pneumatosis (black arrows) without postoperative residual stones.
e40 Biliary duct stone has been regarded as a risk factor for cholangiocarcinoma.5,10 Therefore, malignant tumor should be ruled out in any patient who suffers from choledocholithiasis or hepatolithiasis during preoperative examination and surgical exploration. Resected specimens of the common bile duct and atrophied liver tissue should be examined by an experienced pathologist. The final pathologic examination of surgical specimen in our case demonstrated chronic inflammation and fibrosis with tiny abscess formation in the intrahepatic duct and liver tissue, and chronic cholangitis of common bile duct without any evidence of cholangiocarcinoma. To our knowledge, few cases have been reported with a single gigantic calculus of the common bile duct ⬎10 cm, and most cases are associated with obstructive jaundice and acute cholangitis. In this case, surprisingly, the patient had no symptoms or signs of jaundice and cholangitis. Biliary drainage was likely successful by flowing through some crevices of this gigantic calculus (Fig. 1B). In conclusion, we demonstrate a rare case of a single gigantic calculus of the common bile duct and multiple hepatolithiasis with definite radiologic images. Left hemihepatectomy combined with Roux-en-Y hepaticojejunostomy is an optimal treatment without residual stones in the liver.
The American Journal of Surgery, Vol 202, No 4, October 2011
References 1. Harris HW, Kumwenda ZL, Sheen-Chen SM, et al. Recurrent pyogenic cholangitis. Am J Surg 1998;176:34 –7. 2. Sandler RS, Everhart JE, Donowitz M, et al. The burden of selected digestive diseases in the United States. Gastroenterology 2002;122: 1500 –11. 3. Cheung MT, Kwok PCH. Liver resection for intrahepatic stones. Arch Surg 2005;140:993–7. 4. Liu CL, Fan ST, Wong J. Primary biliary stones: diagnosis and management. World J Surg 1998;22:1162– 6. 5. Su CH, Shyr YM, Lui WY, et al. Hepatolithiasis associated with cholangiocarcinoma. Br J Surg 1997;84:969 –73. 6. Soto JA, Alvarez O, Munera F, et al. Diagnosing bile duct stones: comparison of unenhanced helical CT, oral contrast-enhanced CT cholangiography, and MR cholangiography. AJR Am J Roentgenol 2000;175:1127–34. 7. Polkowski M, Palucki J, Regula J, et al. Helical computed tomographic cholangiography versus endosonography for suspected bile duct stones: a prospective blinded study in nonjaundiced patients. Gut 1999;45:744 –9. 8. Demartines N, Eisner L, Schnabel K, et al. Evaluation of magnetic resonance cholangiography in the management of bile duct stones. Arch Surg 2000;135:148 –52. 9. Uchiyama K, Kawai M, Ueno M, et al. Reducing residual and recurrent stones by hepatectomy for hepatolithiasis. J Gastrointest Surg 2007;11:626 –30. 10. Hammill CW, Wong LL. Intrahepatic cholangiocarcinoma: a malignancy of increasing importance. J Am Coll Surg 2008;4:594 – 603.
Clinical Images
Single gigantic calculus of common bile duct and multiple hepatolithiasis Yiping Mou, M.D., F.A.C.S., Huijiang Zhou, M.D.*, Bin Xu, M.D. Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China KEYWORDS: Choledocholithiasis; Hepatolithiasis; Hepatectomy; Biliary surgery
Abstract. Choledocholithiasis is a very common surgical disease worldwide. Reports of a single calculus of the common bile duct ⬎10 cm are very rare. The authors present a case of a single gigantic calculus in the common bile duct with multiple stones distributing in the left intrahepatic ducts. The patient was treated with left hemihepatectomy combined with Roux-en-Y hepaticojejunostomy, and the postoperative course was uneventful. Left hemihepatectomy combined with Roux-en-Y hepaticojejunostomy was the optimal treatment for this patient, with a satisfactory outcome. © 2011 Elsevier Inc. All rights reserved.
Common bile duct stones and hepatolithiasis are prevalent in developing countries in East Asia, especially in China, and recently have also been encountered with increasing frequency in some Western countries, such as the United States.1,2 Choledocholithiasis and hepatolithiasis are of special clinical significance because of their close association with biliary colic, acute pancreatitis, and cholangitis and can even lead to cholangiocarcinoma due to repeated episodes of cholangitis.3–5 In this report, we present a rare case of a single gigantic calculus in the common bile duct along with multiple calculi dispersed in left intrahepatic ducts.
Case report A 51-year-old woman presented with a 1-year history of diabetes mellitus with chronic intermittent vague pain in the right upper quadrant without fever or icteric sclera for ⬎18 years. On admission, the physical examination revealed a firm, palpable lump approximately 8 cm in diameter under * Corresponding author. Tel.: 86-571-86006291; fax: 86-571-86060497. E-mail address: [email protected] Manuscript received April 12, 2010; revised manuscript July 24, 2010
0002-9610/$ - see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2010.07.043
her xiphoid process, without tenderness. Routine laboratory analysis showed slight elevations in serum alkaline phosphatase level (125 U/L; normal range, 30 –110 U/L) and ␥-glutamyltransferase levels (99 U/L; normal range, 5–50 U/L), with normal levels of serum aspartate amino transferase (23.3 U/L), alanine aminotransferase (29 U/L), and total bilirubin (.45 mg/dL). Computed tomography and magnetic resonance imaging of the abdomen revealed multiple intrahepatic duct calculi with severe atrophy of the left liver lobe and segment V (Fig. 1A), as well as a single gigantic calculus approximately 12.5 cm in length in the common bile duct (Figs. 1B and 2). The patient was treated with left hemihepatectomy combined with resection of segment V and the common bile duct and Roux-en-Y hepaticojejunostomy. Postoperative pathologic findings showed multiple intrahepatic bile duct stones with tiny abscess formation. Chronic cholangitis of the common bile duct was also indicated. The postoperative course was uneventful, and the patient was discharged 12 days after the operation in good condition. Four months later, the patient returned for a checkup, without any complaints of fever or pain. Reexamination on computed tomography indicated mild left hepatic inflammatory effusion and biliary pneumatosis without postoperative residual stones (Fig. 3).
Y. Mou et al.
Single gigantic choledocholithiasis and multiple hepatolithiasis
e39
Comments Choledocholithiasis and hepatolithiasis are common surgical diseases worldwide and should be considered in patients with elevated liver function studies, jaundice, acute pancreatitis, radiologic signs of dilated intrahepatic or extrahepatic ducts, or ultrasound evidence of common bile duct stones. In the past 2 decades, imaging technology has markedly improved. In combination with clinical symptoms and laboratory abnormalities, physicians are able to think of specific clinical questions or possible diagnoses. Specifically, ultrasound examination has become an initial step in management, allowing physicians to identify patients who have potential biliary obstruction diseases. Computed tomographic scans are routinely performed, with sensitivity of 65% to 93% and specificity of 84% to 100%.6,7 Better options include magnetic resonance imaging and endoscopic ultrasound, with sensitivity and specificity ⬎ 90%.6 – 8 Abdominal computed tomography of the patient
Figure 2 Magnetic resonance imaging indicated a single gigantic stone in the common bile duct (white arrows). Inset showing this single gigantic calculus removed from common bile duct measuring 12.5 ⫻ 6.5 ⫻ 5.0 cm. G ⫽ gallbladder; L ⫽ liver.
showed multiple intrahepatic ducts calculi with severe atrophy of left liver lobe and segment V. Depending on the location, size, and quantity of calculi, or on whether there is any complication of severe bile duct infection, appropriate surgical procedures should be considered, such as endoscopic retrograde cholangiopancreatography, and sphincterotomy, laparoscopic or open common bile duct exploration or combined with hepatectomy. The main purpose of these surgical treatments is to remove inflammatory tissue and calculi, relieve ductal stenosis, and improve biliary drainage.9
Figure 1 (A) Contrast-enhanced computed tomography showed multiple intrahepatic duct calculi with severe atrophy of the left liver lobe and segment V (black arrows). (B) A single gigantic stone in the common bile duct (white arrows) and some crevices of this gigantic calculus (black arrows). G ⫽ gallbladder; L ⫽ liver.
Figure 3 Reexamination on computed tomography indicated mild left hepatic inflammatory effusion (white arrow) and biliary pneumatosis (black arrows) without postoperative residual stones.
e40 Biliary duct stone has been regarded as a risk factor for cholangiocarcinoma.5,10 Therefore, malignant tumor should be ruled out in any patient who suffers from choledocholithiasis or hepatolithiasis during preoperative examination and surgical exploration. Resected specimens of the common bile duct and atrophied liver tissue should be examined by an experienced pathologist. The final pathologic examination of surgical specimen in our case demonstrated chronic inflammation and fibrosis with tiny abscess formation in the intrahepatic duct and liver tissue, and chronic cholangitis of common bile duct without any evidence of cholangiocarcinoma. To our knowledge, few cases have been reported with a single gigantic calculus of the common bile duct ⬎10 cm, and most cases are associated with obstructive jaundice and acute cholangitis. In this case, surprisingly, the patient had no symptoms or signs of jaundice and cholangitis. Biliary drainage was likely successful by flowing through some crevices of this gigantic calculus (Fig. 1B). In conclusion, we demonstrate a rare case of a single gigantic calculus of the common bile duct and multiple hepatolithiasis with definite radiologic images. Left hemihepatectomy combined with Roux-en-Y hepaticojejunostomy is an optimal treatment without residual stones in the liver.
The American Journal of Surgery, Vol 202, No 4, October 2011
References 1. Harris HW, Kumwenda ZL, Sheen-Chen SM, et al. Recurrent pyogenic cholangitis. Am J Surg 1998;176:34 –7. 2. Sandler RS, Everhart JE, Donowitz M, et al. The burden of selected digestive diseases in the United States. Gastroenterology 2002;122: 1500 –11. 3. Cheung MT, Kwok PCH. Liver resection for intrahepatic stones. Arch Surg 2005;140:993–7. 4. Liu CL, Fan ST, Wong J. Primary biliary stones: diagnosis and management. World J Surg 1998;22:1162– 6. 5. Su CH, Shyr YM, Lui WY, et al. Hepatolithiasis associated with cholangiocarcinoma. Br J Surg 1997;84:969 –73. 6. Soto JA, Alvarez O, Munera F, et al. Diagnosing bile duct stones: comparison of unenhanced helical CT, oral contrast-enhanced CT cholangiography, and MR cholangiography. AJR Am J Roentgenol 2000;175:1127–34. 7. Polkowski M, Palucki J, Regula J, et al. Helical computed tomographic cholangiography versus endosonography for suspected bile duct stones: a prospective blinded study in nonjaundiced patients. Gut 1999;45:744 –9. 8. Demartines N, Eisner L, Schnabel K, et al. Evaluation of magnetic resonance cholangiography in the management of bile duct stones. Arch Surg 2000;135:148 –52. 9. Uchiyama K, Kawai M, Ueno M, et al. Reducing residual and recurrent stones by hepatectomy for hepatolithiasis. J Gastrointest Surg 2007;11:626 –30. 10. Hammill CW, Wong LL. Intrahepatic cholangiocarcinoma: a malignancy of increasing importance. J Am Coll Surg 2008;4:594 – 603.