P0162 - Stumped by Stones: A Teaching Point about Symptomatic Choledocholithiasis With Persistently Negative Imaging Findings

Fernando Sosa, BS¹, Kazi T. Haque, MD², Patrick Boddie, MD³, Sean Ngo, BS¹, Rohan Patil, BS¹, Jacob Pierce. Reitnauer, BS¹, Rohan Ahuja, MD¹, Iyad Al-bustami, MD, MPH(c)⁴, Austin Thomas, DO⁵, Kevin K. Yu, MD¹, Victor Machicao, MD^1
1University of Texas Health, McGovern Medical School, Houston, TX; ²University of Texas Health, McGovern Medical School, Pearland, TX; ³Baylor College of Medicine, Houston, TX; ⁴Brooklyn Hospital Center, Houston, TX; ⁵McGovern Medical School at UTHealth, Houston, TX

Introduction: Patients with choledocholithiasis often present with right upper quadrant (RUQ) pain with cholestatic liver injury. Imaging modalities such as abdominal ultrasound (US), magnetic resonance cholangiopancreatography (MRCP), or hepatobiliary iminodiacetic acid (HIDA) scan can be ordered as diagnostic modalities. On rare occasions, imaging can be inconclusive, and patients can be improperly diagnosed and treated. Here, we present a case of choledocholithiasis with negative imaging findings that ultimately required endoscopic retrograde cholangiopancreatography (ERCP).

Case Description/Methods: A 57-year-old woman with history of laparoscopic cholecystectomy due to cholecystitis 3 weeks prior presented to the emergency room with severe RUQ pain. Liver function tests were elevated, but abdominal US, computed tomography scan, and MRCP were all negative for abnormalities. An endoscopic US (EUS) was also performed but negative for stones. After controlling her pain, she was discharged.

She then presented the following week and tearfully stated that since her surgery, she has had many episodes of severe abdominal pain with no apparent triggers and not resolved by analgesics. Repeat MRCP and HIDA scan were unrevealing. She was severely distressed by the negative findings and her relentless pain. Due to her overall concerns, ERCP was performed and found significant small stones and sludge burden in the common bile duct (CBD) requiring removal. Her symptoms resolved post-procedure and was discharged home.

Discussion: MRCP has high accuracy rates with 90% sensitivity and 95% specificity for choledocholithiasis. For CBD stones smaller than 5 mm, its sensitivity may decrease. This could be attributed to the lack of contrast between the stones, surrounding liver, and the CBD walls, underexposing the stones to viewers. Furthermore, her EUS was negative despite it having a sensitivity of 95 % to detect stones. In this patient with a high suspicion for choledocholithiasis based on her symptoms, the ERCP treated and prevented her from complications from choledocholithiasis such as cholangitis or pancreatitis. This case serves as a reminder that physicians must incorporate their judgement into clinical decision making as relying solely on objective findings may lead to undesirable outcomes. Although current imaging modalities are highly sensitive, there are limitations on rare occasions. Holistic and individualized patient care based on the clinical synthesis of data and symptoms is the best approach to patient care.



Disclosures:


Fernando Sosa, BS¹, Kazi T. Haque, MD², Patrick Boddie, MD³, Sean Ngo, BS¹, Rohan Patil, BS¹, Jacob Pierce. Reitnauer, BS¹, Rohan Ahuja, MD¹, Iyad Al-bustami, MD, MPH(c)⁴, Austin Thomas, DO⁵, Kevin K. Yu, MD¹, Victor Machicao, MD¹. P0162 - Stumped by Stones: A Teaching Point about Symptomatic Choledocholithiasis With Persistently Negative Imaging Findings, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.