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| Year : 1982 | Volume
: 28
| Issue : 4 | Page : 233-4 |
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Giant common bile duct stone. (A case report).
MN Ahmed, DP Bhat, HU Zargar, MM Khan
Correspondence Address:
M N Ahmed
How to cite this article:
Ahmed M N, Bhat D P, Zargar H U, Khan M M. Giant common bile duct stone. (A case report). J Postgrad Med 1982;28:233-4
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How to cite this URL:
Ahmed M N, Bhat D P, Zargar H U, Khan M M. Giant common bile duct stone. (A case report). J Postgrad Med [serial online] 1982 [cited 2023 Oct 1 ];28:233-4
Available from: https://www.jpgmonline.com/text.asp?1982/28/4/233/5591 |
Full Text
INTRODUCTION
Stones which produce obstruction of the common bile duct may have arisen in the common bile duct, in the gall bladder or in the hepatic or intrahepatic ducts. The commonest stones which originate in the gall bladder are the infective and cholesterol stones and later they may migrate to the common bile duct while pigment stones usually take origin in the smaller intrahepatic ducts as bile thrombi and then migrate to the common bile duct where they enlarge by getting a pultaceous crust of bilirubin. The size of an obstructing stone varies from a few millmeters in diameter (if impacted in ampulla) to several centimeters. We are presenting a case in whom we removed a giant calculus from the common bile duct measuring 3.5" x 1.5" and weighing 55 gms.
CASE REPORT
A 70 year old Muslim male patient was admitted in the medical ward of S.M.H.S. hospital, Srinagar, Kashmir on 18-12-1976 and later shifted to the surgical services on 28-12-1976 with complaints of pain in the upper abdomen, vomiting, fever, rigors and jaundice of two months duration. Past history was suggestive of biliary colics of 6 years' duration but the patient was never hospitalized during this time. Examinations revealed an ill looking, averagely built patient with mild tinge of jaundice. The abdominal examination revealed tenderness and rigidity in the right upper quadrant. On investigations, haemoglobin was found to be 9 gms%; and TLC of 9600/cumm, with P-75%, L-23% and E-2%. Urine analysis was normal. Liver function tests showed serum bilirubin of 2.8 mg%; total proteins, 6.6 gms%; albumin, 3.9 gms%; globulin, 2,7 gms% and serum alkaline phosphatase, 21 K.A. units. Plain skiagram of the abdomen revealed no abnormality and same was the X-ray chest.
The patient was kept on conservative line of treatment which he responded to Serum alkaline phosphatase came down to 6 K.A. units and jaundice abated. Oral cholecystography was performed which suggested a pathological gall bladder. Patient was subjected to surgery after two months of his hospitalization. On laparotomy, multiple adhesions were found around the gall bladder which were carefully lysed. The gall bladder was unhealthy, contracted and fibrosed with palpable stones in it. Common bile duct was seen to be enormously dilated and thickened with a hard mass felt in its middle portion extending down to the duodenum. Stay sutures were given and the common bile duct opened. A huge big stone was seen in the duct. The stone was irregular and extending downwards into the ampulla of Vater. Posteriorly, the stone was very much adherent to the wall of the common bile duct. Major portion of the stone could be removed en mass but the portion which was adherent with the posterior wall of the duct and extending down into the ampulla was removed piecemeal with difficulty. Dilators were passed upwards into the hepatic ducts and downwards which could go easily. A T-tube was put in and the common bile duct closed around it. The gall bladder was removed which contained two small stones. The post-operative period was uneventful except a small leak of bile around the T-tube which subsided spontaneously within a couple of days. The chemical analysis of the stone showed it to be composed of cholesterol, bilirubin and calcium. The stone measured 3.5" x 1.5" and weighed 55 gm [ Fig. 1 ] .
DISCUSSION
In most of the cases of choledocholithiasis a solitary stone is found in the common bile duct.[1] Walter and Snell[9] reported a solitary stone in twothirds of their cases. There are a few cases when two to six and rarely more stones are reported in the common bile duct. MayoRobson and Dobson[7] once counted 88 and Judd and Marshall,[4], [5] more than 100. In most cases, the stone lies towards the lower end of the common bile duct and some 10 per cent are found lodged in the ampulla.
Common duct stones are usually associated with calculus cholecystitis. The stones in the C.B.D. are oval in shape and conforming to the long axis of the duct. The shape results from the adhesions of biliary debris.[8] Giant gall bladder stones (one measuring 4" in circumference[6] and another six and a half inches long and six inches thick[3]) have been reported. Bahuleyan[2] reported a giant common bile duct calculus measuring 6.5 cms x 3 cms and weighing 40.5 gms in a 38 year old Muslim multipara. No complications like rupture or perforations resulting from giant common bile duct calculus have been reported.
References
| 1 | Aird, I.: "A companion in Surgical Studies," 2nd Edition, E.& S. Livingston Ltd., Edinburg and London, 1958, p. 994. |
| 2 | Bahuleyan, C. K.: Giant common bile duct calculus. Ind. J. Surg" 37: 82, 1975. |
| 3 | Bockus, H. L.: "Gastro-Enterology." Vol. III, 2nd Edition, W. B. Saunders Company, Philadelphia, London & Toronto, 1965, p. 954. |
| 4 | Judd, E. S. and Marshall, J. M.: Gall stones in ampulla of Vater. J. Amer. Med. Assoc., 95: 1061-1064, 1980. |
| 5 | Judd, E. S. and Marshall, J. M.: Gall stones in the common bile duct. Arch. Surg., 23: 175-181, 1931. |
| 6 | Lichtman, S. S.: "Diseases of the Liver. Gall Bladder and Bile Duct." 3rd Edition. Lea and Febiger, Philadelphia, 1953, p. 1198. |
| 7 | Mayo-Robson and Dobson: "Diseases of The Gall Bladder and Bile Ducts." London, 1904. Quoted by Aird (1958).[1] |
| 8 | Sherlock, S.: Gall stones and their complications. In, "Diseases of Liver and Biliary System". 2nd Edition, Blackwell Scientific Publications. Oxford, 1961. p. 657. |
| 9 | Walter and Snell: "Diseases of The Gall Bladder and Bile Ducts." W. B. Saunders Company, Philadelphia and London, 1990. Quoted by Aird (1958).[1] |
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