A207 COMMON BILE DUCT OBSTRUCTION FROM RADIOGRAPHICALLY OCCULT LITHIASIS: A CASE REPORT AND CAUTIONARY TALE
Notice bibliographique
Résumé
Abstract Background Biliary obstruction from choledocholithiasis (CDL) can lead to many serious complications, such as cholangitis and pancreatitis. Among noninvasive diagnostic tests for CDL, MRCP is superior to US and CT with a sensitivity of 89–95%. Despite this, MRCP may not always identify the cause of obstruction, leading to diagnostic dilemmas. Aims We aim to review the various ways that CDL can hide on imaging, specifically MRCP. Methods A 22-year-old male with pyruvate kinase deficiency was admitted to General Surgery for acute cholecystitis, for which he had a laparoscopic cholecystectomy. Preoperative MRCP showed a 3 mm common bile duct (CBD) with no stones; however, gross inspection of the gallbladder showed multiple green stones. Around one month later, he was readmitted to General Surgery for symptomatic biliary obstruction, with total bilirubin 923, ALP 457 and ALT 559. He was not febrile and did not require antibiotics. An MRCP showed a CBD of 10 mm with intra- and extrahepatic biliary dilation, but no obstructing focus was seen. Gastroenterology was consulted for undifferentiated hyperbilirubinemia. After further discussion, an ERCP with sphincterotomy was done the next day which also did not show obstruction. An abdominal US done the day after ERCP showed improvement in biliary dilation. After ERCP, the patient’s symptoms improved. Total bilirubin, ALP, and ALT one month later decreased to 121, 134, and 139 respectively. The hypothesis was that he had an obstructing gallstone that camouflaged within bile on imaging. Consent was obtained from the patient to present this case report. Results Although MRCP is one of the best noninvasive diagnostic tests for CDL, some stones may not appear on imaging. On MRCP, stones usually appear as hypointense spots surrounded by hyperintense bile on T2-weighted imaging. However, sludge can be isointense compared to bile. Additionally, stones impacted at the ampulla of Vater typically are not surrounded by bile and thus may evade detection on MRCP. Small stones <4 mm can be missed as well. CBD dilation greater than 10 mm is also associated with reduced sensitivity of MRCP for CDL. Even with ERCP, small stones may be missed unless seen on direct optical visualization after a blind balloon sweep. Even if no obstructing lesion is seen on imaging, other clinical features can still suggest CDL requiring ERCP. The ASGE 2019 Guidelines on CDL recommend prompt ERCP for patients with total bilirubin >68.4 µmol/L and CBD dilation on imaging. Other radiographic signs suggesting CDL include CBD dilation, papillitis, and pericholecystic fat infiltration on CT, and MRCP findings of CDL-associated inflammation such as biliary wall thickening and periductal edema. Conclusions Even if MRCP does not show obvious obstruction, ERCP should still be considered if the likelihood of CDL remains high. Funding Agencies None
Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.
Comment cette classification a été obtenuedéplier
Prédiction machine sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Le volet Gemma est une étiquette directe du modèle pour chaque travail de la base, lue sur la notice réduite au titre. Le volet Codex est un classifieur appris des 10 348 étiquettes directes de Codex et calibré sur les taux pondérés de l'échantillon; les champs sans appui suffisant ne portent aucun appel Codex. Le mode candidate est l'union des deux volets; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont pas des étiquettes humaines.
Scores du classifieur distillé par catégorie (deux têtes)
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,001 | 0,006 |
| Méta-épidémiologie (sens strict) | 0,002 | 0,002 |
| Méta-épidémiologie (sens large) | 0,002 | 0,002 |
| Bibliométrie | 0,005 | 0,002 |
| Études des sciences et des technologies | 0,004 | 0,003 |
| Communication savante | 0,003 | 0,006 |
| Science ouverte | 0,002 | 0,003 |
| Intégrité de la recherche | 0,012 | 0,006 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,004 | 0,002 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule source (Gemma direct ou Codex distillé), pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».