An elderly lady, one week post laparotomy developed mild RUQ pain with worsening liver function tests.
The Gallbladder was mildly tender to pressure (ultrasonic Murphy's sign). Multiple small, mobile, echogenic masses with shadowing were seen in the fundus and neck of the gallbladder, consistent with stones. Some foci of adenomyomatosis were also seen (characterized by ring down artefact). There was a small amount of pericholecystic fluid (but there was also a small amount of free intra-abdominal fluid, so this may not have been specific for gallbladder pathology.
The common bile duct was mildly dilated. Tracing the duct to the head of the pancreas, three small stones (echogenic masses with shadowning) were seen in the distal CBD.
Unexpectedly, the left kidney was noted to be abnormal (click to view).
The normal measurement of the common bile duct is 6mm but this increases with age (1mm per decade over age 60) and post cholecystectomy, and may not return to normal if it has been obstructed and dilated, even if the obstruction is relieved. As a result, it is not uncommon to see a mildly dilated duct but be unable to determine, based on the ultrasound alone, if obstruction is present. Visualizing stones, as in this case makes the diagnosis of choledocholithiasis as the cause of obstruction more certain. Occasionally stones may be seen which do not cause obstruction (as evidence by absence of symptoms and normal liver function tests)