Clinical Presentation Versus Imaging in the Diagnosis of Choledocholithiasis

Introduction: Most cases of acute gallbladder pathology follow a standard diagnostic course, however, that is not always true. Occasionally, imaging and clinical presentation can seem to contradict. The following case demonstrates how search satisficing bias and an overreliance on imaging studies may prolong and complicate patient care.

Case Study: A 26-year-old Hispanic female presents to the emergency department with complaints of right upper quadrant (RUQ) abdominal pain, clay-colored stool, and dark orange urine. The Emergency Department physician orders an abdominal CT scan based on her 8/10 abdominal pain presentation, which shows cholelithiasis without evidence of cholecystitis. She is then referred to a larger hospital where she undergoes a magnetic resonance cholangiopancreatography (MRCP). The results show cholelithiasis with hydropic gallbladder indicating cholecystitis and an otherwise negative MRCP without a common bile duct (CBD) stone. Of note, her Liver Function Tests (LFT) are elevated. The patient is scheduled for a cholecystectomy. Surprisingly, an intraoperative cholangiogram shows a CBD stone. An Endoscopic retrograde cholangiopancreatography (ERCP) is performed, and the stone is removed. However, her LFTs remain elevated. This is thought to be due to post-procedural edema and orders are put in to recheck labs in the morning. The following morning, the LFTs are elevated even further, with the total bilirubin level up to 6.6 as opposed to 2.7 on admission. Additionally, the patient now exhibits scleral icterus and reports pruritus. The patient is sent for another ERCP where another CBD stone is retrieved. The CBD is swept with a 10 mm balloon to confirm there are no stones remaining. Repeat labs show a total bilirubin of 3.3 and the patient is discharged with instructions to follow up with the gastroenterologist, general surgeon, and her primary care physician.

Discussion: This case exemplifies how good clinical judgment integrates the tenet that structure and function are reciprocally interrelated. Generally, we think of imaging as insight into structure and lab values as a window into function. However, here, the abnormal lab values ultimately led to finding a structural abnormality. Although literature typically recommends a RUQ ultrasound as first-line imaging in similar cases, resource limitations led this patient to undergo an MRCP, which literature says is also a reliable diagnostic tool. Here, imaging did not pick up on the classical presentation, but clinical presentation did. For cost-effectiveness and patient care, it is worthwhile to thoroughly investigate a clinical presentation beyond what initial imaging may indicate.