Dispartity among cholangiograms: a case of spontaneous disappearance of a large stone from the common bile duct and intrahepatic-duct diaphragm associated with multiple intrahepatic stones

Disparity among cholangiograms is rarely observed. The causes of disparity include spontaneous disappearance of gall stone, incomplete filling of smaller branch, technical problems, interpretative errors, and overriding of evidence. 5pontaneous disappearance of gall stone is rare but has been well documented in both radioligic and clinical literatures. Recently we have experienced spontaneous disappearance of a large stone in the common bile duct and this formsthe basis of the present case report. The patient, 53-year-old female, was admitted on January 18, 1982 to 5t. Mary's Hospital, Catholic Medical College because of repeated episodes of pain in the epigastrium and the right upper quadrant for the past 2 months. On admission, physical examination revealed tenderness in the epigastrium and the right μpper quadrant. Laboratory tests revealed bilirubin 2.2 mgfdl and alkaline phosphatase 76 .5 KA/dl. A percutaneous transhepatic cholagiogram(PTC} performed 2 days later revealed a large stone measuring 16 × 26mm in size in the distal CBD. The CBD and CHD proximal to the stone were moderately dilated. Most of the intrahepatic ducts were well delineated without fi lJ ing defect or evidence of stone. However, the in ferior segment of the posterior branch of the right intrahepatic duct (IPRH) was not delineated. The ending of the nonvisualized segment was rather abrupt. The patient suffered severe abdominal pain 2 days after PTC, and was treated with Buscopanø compositum. The attack ceased 20 hours after the onset of colicky abdominal pain. An operation was performed 4 days after PTC. To our surprise there was no stone in the distal CBD. The gallbladder was resected and a T-tube has been placed. A table cholangiogram confirmed disappearance of the stone, but IPRH was agin not opacified except for a short ditance just after bifurcation from the main branch. Eight days after surgery a follow-up T-tube cholangiogram was performed. No residual stone was found in the extrahepatic bile duct. However, IPRH which was not opacifled until then became distinctly visualized demonstrating multiple intra-ductal radiolucent stones, There was a diaphragm-like structure obstructing the lumen and confining the stones located proximally to the site obstructed in the precedent cholangiograms, The radiologic and clinical importances of our observation in this case are four fold: 1. Gall stone up to the diameter of 14 × 23mm can pass through the papilla spontaneously, 2. Repeat diagnostic imaging is imperative when patient became asymptomatic after severe colicky abdominal pain before the intended operation, 3. Without optimal delineation of intrahepatic biliaη radicles, residual stone or stones cannot be exciuded in the cholangiograms, 4. And finally, to avoid misdiagnosis a comprehensive knowledge of normal anatomy of cholangiogram is required.