This is a per-operative cholangiogram. It shows a small filling defect in
the lower end of the common bile duct. Of note the filling defect appears to
be the same size as the gallstones seen in the gallbladder.
This looks like a per-operative cholangiogram. The film is labelled
op chole. The patient's date of birth is in 1955 and the
cholangiogram was taken in 2003. The patient was about 48 when this image was
taken. I can see the cholangiogram catheter clipped into the cystic duct and a
laparoscopic port is seen at about 4 o clock.
The duct appears of normal calibre. There is free flow of contrast into
the duodenum. However, there appears to be a small filling defect in the lower
end of the common duct. This would correspond in size with the gallstones seen
on opening the gallbladder and is highly suspicious for a gallstone in the
lower end of the bile duct.
This patient has an unsuspected gall stone in the lower end of the bile
duct (choledocholithiasis). The rate of unsuspected choledocholithiasis in
patients undergoing laparoscopic cholecystectomy is about 5%. In this
particular patient the per-operative ultrasound was not suspicious for common
bile duct stones, there was no duct dilatation and the intra-hepatic ducts
appeared normal. In addition the liver blood tests were also normal. Most
people would not advocate further per-operative imaging of the biliary tree in
the form of MRCP or ERCP in this situation.
This is not a barium enema. A barium enema is used to examine the colon.
This image does not show any evidence of imaging of the colon.
A percutaneous transhepatic cholangiogram (PTC) will give an image similar to
this, however, a PTC would not be done at the time of cholecystectomy. Looking
closely at the image we can see the cholangiogram catheter in place in the
cystic duct, this is how most per-operative cholangiogram are taken. In a PTC
you may see a skinny needle passing through the liver into the intra-hepatic
bile ducts.
This is not an endoscopic retrograde cholangio-pancreaticogram. No
endoscope is visible and we can see the cholangiogram catheter in place in the
cystic duct.
