Impacted

A 48 year old man presents with worsening pain in the upper abdomen for 1 week, in a background of yellowish discoloration of the eyes and intermittent dark urine for 2 months.

Close questioning reveals no history of similar episodes in the past, or of other medical or surgical diseases. However, he confesses that he postponed seeking medical attention until now, as he was 'scared that he might have a serious illness'.

He has never smoked, and only drinks socially. There is no history of sexual promiscuity, blood transfusions, or intravenous drug abuse.

A complete blood count is only significant for a leukocytosis of 11,000/mm3. A renal profile is within normal parameters, as are serum amylase and lipase levels.

Select Relevant Investigations
Liver Profile

Performed

AST: 208 IU/L (10 - 34)
ALT: 142 IU/L (10 - 40)
ALP: 612 IU/L (44 - 147)
Total Bilirubin: 10.1 mg/dL (0.3 - 1.9)
Direct Bilirubin: 8.3 mg/dL (0 - 0.3)
INR: 1.1 (0.9 - 1.1)
X-Ray Abdomen

Performed

The plain radiograph of the abdomen appears completely normal.
Ultrasound Abdomen

Performed

The gallbladder is contracted, with multiple calculi. The common hepatic duct and proximal biliary tree are dilated, although the common bile duct is normal in diameter. There is no pneumobilia, and the liver and pancreas appear normal.
MRCP

Performed

There are multiple gallstones impacted in Hartmann's pouch and the cystic duct, which appear to be compressing the common hepatic duct. There is associated dilation of the hepatic duct and intrahepatic biliary tree. There is no evidence of cholecysto-biliary or cholecysto-enteric fistula formation.

Select Relevant Management
ERCP with Stenting
Cholecystectomy
Cholestyramine
Ursodeoxycholic Acid