© Frossard and Bonvin; licensee Springer. 2011
Received: 13 December 2010
Accepted: 27 April 2011
Published: 27 April 2011
Biliary stones are usually found in the gallbladder, but about 10-20% may spontaneously migrate into the common bile duct where they either remain trapped or migrate subsequently via the papilla of Vater into the duodenal lumen. In some cases, biliary stones may form de novo in the common bile duct because of local precipitating factors. We here present a spectacular case of huge gallstones impacted in the common bile duct (empierrement of the common bile duct) that led to the development of acute cholangitis with septic shock. Urgent nocturnal percutaneous cholangiography permitted biliary drainage and resolution of the cholangitis while the stones were secondarily removed surgically because of the large size of the stones.
Acute suppurative cholangitis may be fatal unless adequate biliary drainage is obtained in a timely manner. The association of fever and rapid onset of jaundice in elderly patients should always make physicians think of cholangitis.
Gallstone disease is one of the most prevalent of all digestive diseases in the United States and Europe. Gallstones do not induce symptoms in the majority of cases, but only 2% to 4% of patients become symptomatic each year .
Gallstone disease is one of the most prevalent of all digestive diseases in the US and Europe. Gallstones do not induce symptoms in the majority of cases, but only 2% to 4% of patients become symptomatic each year. While the vast majority of patients with gallstone disease should be managed by observation alone, selective cholecystectomy is indicated in defined subgroups of subjects, with an increased risk for the development of gallstone-related symptoms and complications in order to alleviate symptoms of pain, jaundice and to prevent acute pancreatitis, cholangitis and cholecystitis . Common bile duct stones are classified according to their origin: (1) primary bile duct stones, forming initially in the bile duct (i.e., the current case); (2) secondary to gallbladder stones, originating in the gallbladder and passing spontaneously into the bile duct; and (3) secondary to or coexisting with intrahepatic bile duct stones . Patients with infected bile duct stones typically present with fever, abdominal pain and jaundice (Charcot's triad), and in severe cases may also have associated hypotension and mental confusion (Raynold's pentad), which predicts a poor clinical outcome . Precipitating factors of symptomatic stones, such advanced age, comorbid neurological disease and peripapillary diverticulum, were identified as independent risk factors for the development of acute suppurative cholangitis in patients with bile duct stones . In the current case, urgent percutaneous biliary drainage was first performed to stabilize the patient, followed 2 weeks later by biliodigestive anastomosis, as proposed by current available guidelines .
This case illustrates a spectacular impaction of several huge stones in the common bile duct that remained otherwise asymptomatic for years and illustrates the famous Charcot's triad. Acute suppurative cholangitis may be fatal unless adequate biliary drainage is obtained in a timely manner. The major cause of acute suppurative cholangitis is bile duct stones that result either from spontaneous migration from the gallbladder into the common bile duct or appear de novo because of precipitating factors.
Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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