0:00

Okay, here we have a contrast

0:02

enhanced CT scan of the abdomen.

0:04

And as we're coming down, we're already

0:05

seeing these branching tubular fluid-filled

0:07

structures within the hepatic parenchyma.

0:10

As we've talked about previously, this is a beautiful

0:13

example of intrahepatic biliary ductal dilatation.

0:16

Again, these are branching tubes

0:18

right on one side of the portal vein.

0:21

Um, you can imagine that those

0:22

patients coming in jaundice.

0:23

Now, your choices when you get jaundice is:

0:26

Do you want the painless variant of jaundice,

0:28

or do you want the painful variant of jaundice?

0:31

It is the, would you rather of all, would you rathers?

0:34

And I suggest you take the pain here because

0:36

painless jaundice, we're always concerned

0:38

about an obstructing lesion and the pancreas.

0:40

But here this patient came in with pain.

0:42

Alright?

0:43

So they've come to the ER, we didn't just take

0:44

'em off the street, they came to the ER with pain.

0:46

So we're going to try to figure

0:47

out if we can find out why.

0:49

They have intrahepatic biliary

0:51

ductal dilatation, and pain.

0:53

Notice that the common bile duct here is very enlarged.

0:56

Here's the gallbladder posteriorly.

0:57

The gallbladder looks distended, but there's

0:59

not a lot of inflammatory change around it, and

1:01

the wall actually looks fairly thin as well.

1:04

Now, as we come down, you're going to see,

1:07

huh, a funny change in density within

1:09

the lumen of the common bile duct.

1:11

You can see that nice rim of lower

1:13

attenuation with something that looks a

1:15

little bit more like soft-tissue within it.

1:17

Coming down, you can see there's now

1:19

decompression of the common bile duct.

1:20

Let's go coronal on that.

1:22

That's going to be your money shot.

1:24

Coming forward, we're going to see that

1:25

beautiful biliary ductal dilatation.

1:27

Here's the common bile duct.

1:28

It is very, very dilated.

1:30

And now you can make out this very circular,

1:33

soft-tissue attenuation region within it.

1:35

Now, that's not actually a soft-tissue lesion.

1:37

That is the appearance of a gallstone.

1:40

A noncalcified gallstone within the

1:43

common bile duct is causing obstruction,

1:46

causing jaundice, likely causing quite a bit

1:48

of pain as that tries to transition through

1:51

the common bile duct into the duodenum.

1:53

Not a good chance of that occurring here.

1:56

This patient is going to need to go for an

1:58

ERCP in order to cannulate the, uh, sphincter

2:01

and allow that stone to be released

2:03

and passed through the common bile duct.

2:06

Okay, so here we have a right upper quadrant

2:08

ultrasound with a large number of images to look at.

2:12

But you know, we're not intimidated.

2:13

That's not going to happen for us.

2:15

Um, and already you can see those little

2:16

tiny echogenic surrounded tubular structures

2:19

within the liver, consistent with intra

2:22

hepatic biliary ductal dilatation.

2:23

So already we have some

2:24

intrahepatic bile duct dilatation.

2:27

Here we have the gallbladder with

2:28

just beautiful layering sludge.

2:30

Look at that.

2:31

This is the choledochal bile with the various

2:33

degrees of choledochal layering bile sludge.

2:37

It actually kind of looks like Neapolitan

2:38

ice cream if you look at it carefully.

2:40

But in the central, we see intrahepatic biliary

2:42

ductal dilatation as outlined by our technologist.

2:45

That's amazing.

2:46

And as we come down, we're going to maybe

2:48

take a sweep here of the common bile duct.

2:51

And we're going to see what we see because this

2:53

patient has a very dilated common bile duct.

2:55

And within the common bile duct, we

2:56

have a gigantic rock there trying to

2:58

roll its way down the common bile duct.

3:00

And that is choledocholithiasis in its most extreme form.

3:04

So you always want to follow on your sweeps,

3:06

because the choledocholithiasis isn't always this beautifully

3:09

imaged on the sweep images, and frequently you

3:11

have to keep on going until you find, oh yes, there

3:15

is another stone at the pancreatic head as well.

3:18

So don't let just one stone be the find.

3:21

You want to find all the stones.

3:22

Here we can see the portal vein is adjacent to that

3:25

dilated common bile duct going into the liver as well.

3:28

You can see that kind of that pulsating appearance

3:30

on the sweep images, so there is choledocholithiasis

3:34

causing upstream dilatation of the intra

3:36

hepatic ducts and distension of the gallbladder.

3:40

Let's take a look at this patient's MRCP.

3:42

Now that was very diagnostic.

3:44

Again, I can't stop the CTs

3:46

that happen in our hospital.

3:46

We're really big fans.

3:47

It seems to be our surgeons' best way to

3:50

sleep through the night is to suggest an

3:51

MRCP so that they can wait till morning.

3:53

But the delay tactics are real.

3:56

And due at tribute to our increasing load of CTs.

3:59

But I don't want you to think that they're anything

4:01

but fun because they're very, very beautiful.

4:03

Here again, we have intrahepatic

4:04

biliary ductal dilatation.

4:06

We have a very dilated common bile duct.

4:09

As you come down, you have this beautiful

4:10

intrahepatic choledocholithiasis within the common

4:14

bile duct, and one at the ostium of the

4:17

sphincter as well.

4:19

So this is extreme choledocholithiasis, well imaged on

4:24

every variant of CT scan, ultrasound, and MRI.