A Rare Etiology of Obstructive Jaundice in a patient of Cholelithiasis

A 76-year-old female patient of chronic obstructive airway disease presented with intermittent episodes of epigastric and right hypochondric pain of moderate to severe intensity associated with nausea and occasional vomiting for the last 2 months. Her general physical and systemic examination was normal. Laboratory investigations revealed normal hemogram and renal biochemistry. Liver function tests showed mildly elevated total bilirubin (2.1 mg/dL), conjugated bilirubin (1.4mg/dL), and alkaline phosphatase (310 IU/L), with normal levels of alanine aminotransferase and aspartate aminotransferase.

Abdominal ultrasonography revealed cholelithiasis with proximal dilatation of the common bile duct (CBD). The distal CBD, however, could not be adequately visualized due to bowel gas artifact. Magnetic resonance cholangiopancreatography (MRCP) was subsequently performed to exclude concomitant choledocholithiasis. MRCP findings confirmed cholelithiasis with dilatation of the CBD (11.7 mm) and common hepatic duct (CHD) (10.4 mm), along with a prominent pancreatic duct, without evidence of an intraductal calculus ([Fig 1A]). Her contrast-enhanced computed tomography revealed dilated CBD throughout its course with its compression in the periampullary region by a duodenal diverticulum seen arising medially from the second part of the duodenum ([Fig 1B]). Her side viewing endoscopy revealed a large diverticulum arising from the distal medial wall of the second portion of the duodenum ([Fig 1C]).

Fig. 1 (A) Magnetic resonance cholangiopancreatography image showing dilated common bile duct (CBD) and common hepatic duct (CHD) with prominent pancreatic duct with narrowing at distal CBD. (B) Computed tomography image showing dilated CBD with its compression in the periampullary region by a duodenal diverticulum (blue arrow) arising from the second part of the duodenum. (C) Side view endoscopy image showing a large diverticulum (yellow arrow) in the second part of the duodenum. (D) Cholangiography image dilated CBD and CHD without any obvious filling defect.

In view of dilated biliary system and raised bilirubin and alkaline phosphatase level endoscopic retrograde cholangiopancreatography (ERCP) was performed under propofol sedation. A triple-lumen sphincterotome (CleverCut 3V, Olympus) and a 0.025-inch guidewire (VisiGlide, Olympus) were utilized to cannulate CBD. Cholangiography showed dilated CBD and CHD without any obvious filling defect or mass ([Fig 1D]) and endoscopic sphincterotomy was performed. Following the procedure, repeat liver function tests performed at 2 weeks demonstrated significant improvement, with total bilirubin decreasing to 1.0 mg/dL, conjugated bilirubin to 0.6 mg/dL, and alkaline phosphatase to 128 IU/L. The patient was subsequently referred to the department of surgery for elective cholecystectomy.

Authors' Contributions

All authors contributed equally to the article.

Patient's Consent

The patient provided informed consent to publish the included information.

Publikationsverlauf

Artikel online veröffentlicht:
07. November 2025

• References

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