Content area
Full text
Case report
A previously healthy woman aged 54 years presented with a 3 week history of colicky right upper quadrant pain together with progressive jaundice and pruritus. She also reported the recent onset of dark urine and pale stools. Her only previous medical history was arterial hypertension controlled with atenolol 50 mg daily. There were no notable risk factors for chronic liver disease. Physical examination revealed obvious icterus with scattered excoriation marks but no evidence of bruising, spider naevi, distended abdominal veins or ascites. She was not feverish and was not encephalopathic.
Laboratory blood tests showed an elevated bilirubin of 275 [micro]mol/l (16.2 mg/dl), alkaline phosphatase (ALP) 195 IU/l (30-115) and aspartate transaminase 50 IU/l (5-45). Prothrombin time was 11.8 s (laboratory range 11.0-13.5) and full blood count, C reactive protein, urea, electrolytes and serum amylase were all within normal limits. Trans-abdominal ultrasound demonstrated moderately dilated intrahepatic bile ducts and a dilated common bile duct (CBD) measuring 10 mm in diameter. There were multiple calculi visible in both the CBD and in the contracted gallbladder. The patient was prescribed oral ciprofloxacin 500 mg twice daily and endoscopic retrograde cholangiopancreatography (ERCP) was arranged.
At ERCP, duodenal intubation revealed a bulging papilla and the cholangiogram confirmed multiple stones in the CBD ( figure 1 ). A sphincterotomy was performed and a balloon trawl extracted multiple small stones with effective clearance of the duct confirmed on a closing cholangiogram. The fully inflated balloon was able to traverse the sphincterotomy, which was considered sufficiently wide to allow spontaneous passage of any further stones.
However, the patient remained jaundiced and liver biochemistry 3 days after the ERCP demonstrated a further deterioration, with bilirubin now 488 [micro]mol/l (28.7 mg/dl), ALP 177 IU/l and aspartate transaminase 64 IU/l. A second ERCP was therefore carried out on day 10 to exclude persistent choledocholithiasis. On this occasion, there was a mildly dilated CBD but no intraductal stones and the retrieval balloon easily traversed the widely patent sphincterotomy ( figure 2 ).
Despite this apparent confirmation of effective duct clearance, the patient continued to deteriorate clinically and biochemically, as evidenced by progressive jaundice, intense pruritus, anorexia and nausea associated with rising levels of bilirubin and ALP. At this stage ciprofloxacin was stopped and she...