Ghulam Sabir Iqbal, Muhammad Aslam, Mohammad Asghar Ali.
Common Bile Ductal Calculi with intra-hepatic extention.
Pak Armed Forces Med J Jan ;52(1):114-5.

An elderly lady, housewife, presented to us with H/O vague abdominal pain in RT upper abdomen for the last three months. She however gave H/O slight dyspeptic symptoms. She was passing normal colored stools. She did not give any H/O weight loss. On examination abdomen was soft, mild tenderness noted in the RT hypochondrium. She looked slightly pale. Her respiratory and cardiovascular svstems did not reveal any abnormality. On investigations her Hb was 9.lgm%, TLC. DLC were within in normal limits. Her blood urea & blood sugar were normal. LFT, Serum-Bilirubin was 10 umol/l. Serum Alkaline phosphatase was 461 (normal up to 300 u/1), X-ray chest did not reveal any abnormality. Liver Showed smooth margins and normal echotexture. There were multiple dilated intrahepatic channels. Tiny echogenic foci were noted in the line of RT biliary duct and these might represent intra-hepatic Caculi, the proximal CBD was dilated and showed a stone in it, measuring 2.1 cm in size. Gall Bladder was hardly visible. A vague area below the porta represented a fibrosed Gall Bladder. ERCP could not outline the CBD, only pancreatic duct could be outlined. Therefore, PTC was requested which was suggestive of CBD Calculi with right hepatic stones. Gall Bladder was not visualised and so was Cystic duct. So she was diagnosed to be a case of CBD Calculi with intrahepatic Calculi. She was operated upon. Difficult adhesions were broken to reach the Gall Bladder, which was found fibrosed lying in the Gall bladder bed of liver. Cholecystectomy was performed. CBD was washed. The small Calculi continued coming from RT Hepatic duct. A Foley`s catheter of 10f was passed, balloon was inflated slightly, and the intra hepatic stones were retrieved with multiple attempts. Then the bypass was done by doing Choledocoduodenostomy, end to side. She made uneventful recovery post-operatively and was discharged from the hospital after 10 days.

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