MyPACS.net: Radiology Teaching Files > Case 218550

never visited STONE IN DISTAL CBD AT PANCREATIC HEAD
Contributed by: Melissa Tracey, M.Ed., RT(R), Lutheran General Hospital, Illinois, USA.
Patient: 6 year old female
History: Patient presented with hepatitis and RUQ pain.
Images:[small]larger

Fig. 1: Decubitus view of gallbladder shows calculi in fundus with acoustical shadowing.

Fig. 2: Transverse scan through pancreas shows stone in distal common duct with acoustical shadowing.

Fig. 3: Scan along long axis of common bile duct demonstrates mild duct dilatation and stone distally.

Fig. 4: MRCP shows stones in fundal region of gallbladder, stone in distal common bile duct, and duct dilatation.
Findings:

Sonographic images through the pancreas show an echogenic focus in the head of the pancreas with acoustical shadowing representing a calculus in the distal common duct. There is a moderate degree of intrahepatic duct dilatation.

Scanned sections through the gallbladder show a well distended Gb with calculus in the fundus of the Gb with associated acoustical shadowing.

Diagnosis: Cholelithiasis and Choledocholithiasis
Discussion:

Stones in the CBD usually originate in the Gb and migrate distally. Calculi can obstruct anywhere in the biliary duct, but most often cause obstruction at the level of the pancreatic head. Data are lacking in children, but in adults, the sensitivity of sonography for detecting choledocholithiasis is between 55% and 80%. The sensitivity is lower for stones distally versus the proximal duct. A distal impacted calculus is more difficult to detect because of adjacent or overlying bowel gas and because the calculus is surrounded by the echogenic pancreatic head.

At sonography, bile duct calculi are seen as echogenic foci, usually with acoustic shadowing. About 10% of duct stones in adults do not cause acoustic shadows. As many as 25% of adults with bile duct stones have normal (non-dilated) ducts.

The common causes of cholelithiasis in older children and adolescents include cystic fibrosis, malabsorption, total parenteral nutrition, liver disease, Crohn's disease, bowel resection, and hemolytic anemia. Less commonly, gallstones have been associated with the use of drugs (particularly, ceftriaxone and cyclosporine) and metachromatic leukodystrophy.

Gallstones may be composed of cholesterol, pigment (calcium bilirubinate) or calcium carbonate. About 90% of gallstones have a mixed composition. Pure cholesterol stones represent 10% of all stones, and pure calcium carbonate stones are rare. Pigment stones account for a higher percentage of stones in prepubertal children, whereas cholesterol stones are relatively more common in adolescents and adults. Unless symptomatic, gallstones do not require surgical intervention and often resolve without treatment.

* Special thanks to John McFadden MD, Radiologist, Lutheran General Hospital, Park Ridge, Illinois and Marianna Desmond, Sonography Instructor, Triton Community College, River Grove, Illinois.


References:

Siegel M. Gallbladder and Biliary Tract. In: Siegel M. ed. Pediatric Sonography. 3rd Edition. Philadelphia: Lippincott, 2002; 298-301.

Laing FC. Ultrasound diagnosis of choledocholithiasis: A Reappraisal. Radiology 1986; 161:133.

Tomooka Y, Koga T, Onitsuka H, et al. Ultrasonic demonstration of a common bile duct calculus associated with congenital bile duct dilatation. Pediatric Radiology 1988; 18: 499-500.

Brunelle F. Choledocholithiasis in children. Semin Ultrasound CT MR 1987; 8:118-125.

Gilger MA. Diseases of the gallbladder. in: wyllie R, Hyams JS, eds. Pediatric gastrointestinal disease. 2nd ed. Philadelphia: WB Saunders, 1999:651-662

Gubernick Ja, Rosenberg HK, Ilaslan H, et al. US approach to jaundice in infants and children. Radiographics 2000;20:173-195.

Comments:
--Melissa Tracey, M.Ed., RT(R), 2003-11-11
Additional Details:

Case Number: 218550Last Updated: 11-23-2005
Anatomy: Gastrointestinal (GI)   Pathology: Metabolic
Modality: MR, USExam Date: 11-11-2003Access Level: Readable by all users
Keywords: cholelithiasis, common duct stone

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