Characterization of primary pure cholesterol hepatolithiasis: cholangioscopic and selective cholangiographic findings

Primary pure cholesterol hepatolithiasis has been described recently. The aim of this study was to analyze its clinical and radiologic features, focusing on the cholangioscopic and selective cholangiographic findings.

Primary pure cholesterol hepatolithiasis was identified in 3% (6 of 172) of patients who were treated with cholangioscopic stone removal for primary hepatolithiasis during the study period from 1995 to 1999. These 6 consecutive patients (M/F 5:1, mean age 40 years) were enrolled in the study. They underwent abdominal US, CT, endoscopic retrograde cholangiography (ERC), and percutaneous transhepatic cholangioscopy (PTCS). After confirming that the stones were of the cholesterol type, cholangioscopic stone removal via the percutaneous transhepatic route was performed. For the prevention of recurrence, ursodeoxycholic acid (10 mg/kg/day) was prescribed during follow-up.

US demonstrated high echogenicity with strong shadowing in dilated peripheral ducts, whereas CT failed to demonstrate any intraductal abnormal density or calcification except localized duct dilatation. PTCS demonstrated multiple, white to yellowish stones that were morphologically readily distinguishable from brown pigment intrahepatic stones. In all patients, selective cholangiography disclosed the ductal abnormalities, which could not be delineated by ERC in 4 patients. Complete stone removal by PTCS was achieved in 5 of 6 patients. During follow-up (12 to 49 months, mean 22 months), they were asymptomatic and stone recurrence was not detected by US.

Primary pure cholesterol hepatolithiasis is distinguishable from the more common brown pigment hepatolithiasis by its cholangioscopic and selective cholangiographic characteristics.