Images in Clinical Medicine
Biliary Sludge Extruding into the Duodenum
N Engl J Med 1998; 339:1210October 22, 1998
- Article
Figure 1 A 77-year-old man presented with fever, jaundice, and pain in the right upper quadrant. In the past, he had had a permanent pacemaker implanted and had undergone a right hemicolectomy for adenocarcinoma of the colon and partial resection of the small intestine for acute mesenteric arterial occlusion. On examination, he had a temperature of 37.4°C, a pulse of 70 per minute, and a blood pressure of 140/80 mm Hg. There was tenderness on palpation of the right upper quadrant, without rebound tenderness or guarding. The results of laboratory tests were as follows: white-cell count, 5700 per cubic millimeter; hematocrit, 30 percent; platelet count, 179,000 per cubic millimeter; serum total bilirubin, 8.9 mg per deciliter (153 μmol per liter); aspartate aminotransferase, 203 U per liter; alanine aminotransferase, 161 U per liter; lactate dehydrogenase, 731 U per liter; and alkaline phosphatase, 373 U per liter. Endoscopic retrograde cholangiopancreatography revealed biliary calculi and sludge in the gallbladder and the common bile duct. As is evident in the photograph, biliary sludge extruded into the duodenum from the ampulla of Vater immediately after the cannula was removed. At surgery, the patient was found to have calculous gangrenous cholecystitis and choledocholithiasis. A cholecystectomy and a choledocholithotomy were performed, and a T tube was left in place. The patient's condition improved, but 3 weeks later enterococcal sepsis developed and he died 30 days postoperatively despite aggressive therapy with antibiotics, fluids, and plasma.
Akira Hokama, M.D.
Fukunori Kinjo, M.D.
University of the Ryukyus, Okinawa 903-01, Japan- Citing Articles (2)
- Letters
