Images in Clinical Medicine
Biliary Stones
N Engl J Med 2009; 360:2563June 11, 2009
- Article
A 63-year-old woman presented with a 2-day history of fever, abdominal pain, and vomiting. There was no history of previous episodes. Physical examination revealed fever and moderate abdominal tenderness in the right upper quadrant, without jaundice. The white-cell count was 9100 per cubic millimeter, with a normal neutrophil count but 29% band forms. The bilirubin, alkaline phosphatase, aspartate aminotransferase, and alanine aminotransferase levels were normal. Computed tomography of the abdomen revealed multiple stones in the intrahepatic and common bile ducts (asterisks) with diffuse dilatation of the biliary tract (arrows). The stones were not amenable to endoscopic removal; therefore, endoscopic nasobiliary drainage was performed. Cultures of the drainage fluid grew Enterococcus faecalis. The fever and abdominal pain subsided after 2 days of drainage and antibiotic therapy. Surgical stone removal was recommended, but the patient declined, and instead, a biliary stent was inserted endoscopically into the common bile duct. Follow-up abdominal ultrasonography at 3 months revealed that the stent had been dislodged and passed. The stones were still present, but the ductal dilatation was improved. Despite having declined placement of a new stent, the patient remained asymptomatic 1 year later.
Ping-Hsien Chen, M.D.
Chiao-Hsiung Chuang, M.D.
National Cheng-Kung University Medical Center, Tainan 70428, Taiwan
jasonc@mail.ncku. edu. tw
