A 43-Year-Old Woman With a 7-Month History of Intermittent Abdominal Pain and Weight Loss

Ann S. Fulcher, MD; Aneesa S. Majid, MD; Timothy J. Broderick, MD; Medical College of Virginia of Virginia Commonwealth University, Richmond.


November 09, 2001

Therapeutic Interventions and Clinical Outcome

The patient underwent ERCP to remove the ductal calculi. ERCP (see Figure 2) revealed multiple intraductal calculi as well as intrahepatic and extrahepatic biliary ductal dilatation. Performance of a sphincterotomy and balloon extraction resulted in removal of multiple pigmented stones from the extrahepatic and intrahepatic ducts. At completion of the procedure, multiple stones remained in the ducts. A 10-French, 15-cm biliary stent was left in place. One month later, the patient underwent a second ERCP during which balloon extraction of multiple ductal stones was performed. At the completion of this second ERCP, a 10-French, 15-cm biliary stent was left in place.

Because the patient continued to experience abdominal pain during the subsequent 4 months, she was referred for surgery. Intraoperative findings confirmed that the disease primarily involved the left hepatic lobe, which showed evidence of marked atrophy. Therefore, a left hepatic lobectomy was performed The surgical specimen (see Figure 3) was remarkable for atrophy predominating in the lateral segment. Dilated ducts that contained multiple, hard, black stones were identified. Multiple stones in the extrahepatic duct and a few stones in the right hepatic duct were extracted. After removal of all stones, completion choledochoscopy revealed minimal, residual ductal dilatation without strictures. A cholecystectomy was also performed. Pathologic evaluation confirmed RPC involving the liver and bile ducts. The resected gallbladder showed evidence of chronic cholecystitis, but no stones.

The cut surface of the resected left hepatic lobe is shown along with pigmented sludge and stones (arrows) removed from the left hepatic ducts.

The patient's postoperative course was uneventful and she has remained asymptomatic for 2 years following left hepatectomy.


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