US QUIZ MAY 2022
Case Report A 64-year-old female was referred for general surgery department for common bile duct (CBD) abnormal dilatation. Her previous medical history included dyslipidemia and depression and she was currently medicated with propranolol, lorazepam and sertraline. Previous surgeries included cholecystectomy, appendectomy and thyroidectomy. Magnetic resonance cholangiopancreatography (MRCP) revealed CBD dilation with a maximal diameter of 14 mm and mild dilation of intra-hepatic bile ducts. Although there were no intraluminal lesions, the dilation appeared to end abruptly at the junction with main pancreatic duct (Fig. 1). Therefore, she undergone endoscopic ultrasound (EUS) that confirmed CBD dilation and hyperechogenic contents were apparent at its distal portion suggestive of biliary sludge. Prompt endoscopic retrograde cholangiopancreatography (ERCP) was performed, but no calculi were identified at cholangiogram or after Fogarty balloon exploration. There were no immediate adverse events. At the following day, the patient complained of abdominal pain and performed an abdominal computerized tomography (CT) where moderate ascites was noted. Laboratory studies revealed leukocytosis and elevated C-reactive protein. Diagnostic paracentesis was consistent with biliary peritonitis and she started intravenous antibiotic therapy with ceftriaxone and metronidazole. Considering a possible biliary perforation, ERCP was repeated. There was no evidence of contrast leakage. Nevertheless, considering biliary ascites, a fully-covered self-expandable metal stent was placed (Fig. 2). She maintained antibiotic therapy for 14 days with clinical and biochemical improvement and undergone repeat abdominal CT which revealed three abdominal fluid collections: one with 14.9×6.9×7.8 cm at retroperitoneal location, one with 6.6×3.4 cm adjacent to gastric posterior wall and one with […]