Abstract
This case report is interesting in radiologically showing migration of stones from the gallbladder via the biliary tree and into the gastrointestinal tract.
Keywords: Radiology, Gallstone migration, Acute pancreatitis
A58-year-old man was admitted with a 72-h history of biliary colic followed by sudden severe epigastric pain radiating to his back. On examination, he was found to have epigastric tenderness. Serum amylase was > 2500 IU/l, liver function test revealed raised alkaline phosphatase of 229 IU/l, ALT 456 IU/l, bilirubin 21 μmol/l and mild hypoxia (pO2 84 mmHg). A diagnosis of acute pancreatitis was made. An abdominal radiograph (72 h after first attack of symptoms) revealed multiple gallstones in the gallbladder as well as small and large intestines (Fig. 1). An MRCP (Fig. 2) carried out about 96 h following onset of symptoms showed multiple gallstones in the gallbladder with smaller stones in the CBD. An ERCP, carried out within 48 h of admission (120 h after onset of symptoms), demonstrated an oedematous papilla indicating recent passage of gallstones, normal CBD as well as stones in the cystic duct (Fig. 3). The pancreatitis resolved within 48 h of admission and a laparoscopic cholecystectomy was carried out on the next elective operating list. A pre-operative radiograph on the 8th day after admission showed passage of stones from the GI tract with more stones poised in the cystic duct (Fig. 4). At operation, the gallbladder was found to contain numerous small gallstones (Fig. 5) connected to a large cystic duct containing a stone. The patient made an uneventful recovery.
Figure 1.
Plain abdominal X-ray demonstrating gallstones in the gallbladder and in the GI tract. A gallstone was suspected to be at the lower end of the CBD (see arrow).
Figure 2.
MRCP demonstrating a gallstone at the lower end of CBD (see arrow).
Figure 3.
ERCP 24 h after the MRCP showing a clear duct and the stone seen in Figure 1 appeared to have passed (see arrow).
Figure 4.
A pre-operative plain abdominal film showing more stones lined up in the cystic duct.
Figure 5.
Stones retrieved from the gallbladder specimen.
Comment
Gallstone migration has been implicated in the pathogenesis of gallstone pancreatitis. Evidence to support this derives from the work of Acosta and Ledesma1 and Mayer and MacMahon 2 in relation to finding of gallstones in the faeces from patients who had recent pancreatitis. In addition, the yield of gallstones in the CBD/ampulla during ERCP or surgery is inversely related to the timing following onset of pancreatitis.3 The present case is interesting in radiologically showing migration of stones from the gallbladder via the biliary tree and into the gastrointestinal tract. The recent development of MRCP has enabled us to demonstrate this in a non-invasive manner.4
References
- 1.Acosta JM, Ledesma CL. Gallstone migration as a cause of acute pancreatitis. N Engl J Med. 1974;290:484–7. doi: 10.1056/NEJM197402282900904. [DOI] [PubMed] [Google Scholar]
- 2.Mayer AD, MacMahon MJ. Gallstone migration and early diagnosis of cholelithiasis in acute pancreatitis [Abstract] Gut. 1983;24:A988. [Google Scholar]
- 3.Armstrong CP, Taylor TV, Jeacock J, Lucas S. The biliary tract in patients with acute gallstone pancreatitis. Br J Surg. 1985;72:551–5. doi: 10.1002/bjs.1800720718. [DOI] [PubMed] [Google Scholar]
- 4.Musella M, Barbalace G, Capparelli G, Carrano A, Castaldo P, Tamburrini O, et al. Magnetic resonance imaging in evaluation of the common bile duct. Br J Surg. 1998;85:16–8. doi: 10.1046/j.1365-2168.1998.00666.x. [DOI] [PubMed] [Google Scholar]