Cholelithiasis and Common Bile Duct Stone

The patient presented with acute pancreatitis, sepsis and septic shock. CT abdomen revealed evidence of pancreatitis as well as distended gallbladder and dilated common bile duct. No gallstones were seen on CT.

The patient was suspected to have a common bile duct (CBD) stone. ERCP was recommended, yet the patient was deemed to be too unstable to undergo the procedure (the patient was on full ventilatory support and multiple vasopressors.

Percutaneous cholecystostomy was recommended as a temporizing measure. An external biliary drain was placed into the gallbladder under direct visualization.

During the procedure the patient was found to have his gallbladder jam-packed with stones (see image above). Also there was evidence of a CBD (labeled CBD on the image above) stone completely blocking the duct - white arrow above.

It is interesting how CT abdomen and, sometimes, even a gallbladder ultrasound can miss such dramatic findings.