A 48-year-old gentleman presented to Dr. Raman Garg with progressive jaundice, upper abdominal pain, fever and deranged liver function tests. Initial ultrasonography suggested a common bile duct (CBD) stone with dilated intrahepatic biliary radicals and a dilated CBD.
Further evaluation revealed a rarer cause of biliary obstruction: a benign common hepatic duct stricture complicated by suppurative cholangitis.
Initial Evaluation
Ultrasound demonstrated dilated intrahepatic biliary radicals, a CBD measuring approximately 14 mm, an echogenic focus reported as a possible CBD stone and post-cholecystectomy status.
Unexpected Finding During ERCP
Therapeutic ERCP with wire-guided cannulation and sphincterotomy demonstrated an abrupt cut-off at the upper CBD/common hepatic duct, a tight benign biliary stricture and persistent biliary obstruction. No calculus could be retrieved.
MRCP Confirmed the Diagnosis
MRCP demonstrated gross dilatation of the right and left hepatic ducts, abrupt narrowing of the common hepatic duct approximately 24 mm below the biliary confluence, a normal distal CBD and no evidence of a CBD stone or mass lesion.
The final diagnosis was a benign post-cholecystectomy common hepatic duct stricture with obstructive jaundice.
Life-Threatening Finding During Surgery
During open biliary exploration by Dr. Raman Garg, the biliary tree was grossly dilated. Opening the CBD released a large amount of frank pus from the CBD and intrahepatic biliary radicals, confirming suppurative cholangitis caused by prolonged biliary obstruction. No CBD stone was identified.
Definitive Surgical Procedure
Dr. Raman Garg performed open common bile duct exploration, evacuation of frank pus, confirmation of the benign stricture, thorough saline irrigation, a wide side-to-side choledochoduodenostomy, abdominal drainage and layer-wise closure.
A wide biliary-enteric bypass was created to provide durable bile drainage and help prevent recurrent obstruction.
Why Was Choledochoduodenostomy Performed?
The patient had a high-grade benign common hepatic duct stricture, failed ERCP, gross biliary dilatation and frank pus indicating severe infection. A durable, low-pressure drainage procedure was required. In carefully selected patients with benign biliary obstruction and a dilated CBD, choledochoduodenostomy can provide long-term biliary drainage.
What Is Suppurative Cholangitis?
Suppurative cholangitis occurs when infected bile becomes trapped behind an obstructed bile duct. Without urgent decompression, it can progress to septicaemia, septic shock, multi-organ failure and death. It requires urgent drainage of the biliary system, either endoscopically or surgically.
Highlights of This Case
- Initially diagnosed as a possible CBD stone
- ERCP demonstrated a benign common hepatic duct stricture
- MRCP confirmed benign biliary obstruction
- Frank pus was found in the CBD and intrahepatic biliary radicals
- Open CBD exploration and wide choledochoduodenostomy were successfully performed
- Complete biliary decompression and excellent postoperative recovery
Learning Point
Not every dilated common bile duct contains a stone. Persistent obstructive jaundice following ERCP, especially when no stone is retrieved, should raise suspicion for benign biliary stricture, post-cholecystectomy bile duct injury, inflammatory fibrosis, cholangiocarcinoma or other causes of extrahepatic biliary obstruction.
Early recognition and timely intervention are essential to prevent recurrent cholangitis, liver damage, biliary cirrhosis and life-threatening sepsis.
Case Summary
| Operating Surgeon | Dr. Raman Garg |
|---|---|
| Hospital | Bombay Gastro & Cancer Institute, Bathinda |
| Patient | 48-year-old Gentleman |
| Initial suspicion | Choledocholithiasis / CBD stone |
| Final diagnosis | Benign common hepatic duct stricture with suppurative cholangitis |
| Procedures | ERCP followed by open CBD exploration and choledochoduodenostomy |
| Outcome | Complete biliary decompression and excellent postoperative recovery |
Frequently Asked Questions
Can a benign biliary stricture mimic a CBD stone?
Yes. Both conditions can cause obstructive jaundice and a dilated CBD, so ERCP or MRCP may be needed to identify the cause.
Why was no stone found during ERCP?
The obstruction was caused by a tight benign common hepatic duct stricture rather than a stone.
What is suppurative cholangitis?
It is a severe infection of the bile ducts caused by obstruction, with accumulation of infected bile or pus. It is a surgical emergency.
Why was choledochoduodenostomy performed?
It provided permanent drainage after ERCP failed to relieve the obstruction caused by the benign stricture.
Patient identity has been withheld to maintain confidentiality. This case is shared for educational purposes only. Individual diagnosis and treatment should always be based on evaluation by a qualified medical professional.
