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The Difficult Path to Correct Diagnosis of Hepatolithiasis: A Case Report
Peter Mikolajčík1, Alexander Ferko2, Michal Demeter3
1Department of Surgery and Transplant Unit, Comenius University in Bratislava, Jessenius Medical Faculty in Martin, University Hospital Martin, Slovak Republic. peto.mikolajcik@gmail.com.
Insights
Hepatolithiasis, or intrahepatic stones, can be misdiagnosed due to atypical presentations. Early and accurate diagnosis via repeated imaging is crucial for effective treatment and improved patient outcomes.
Area of Science:
- Hepatobiliary Medicine
- Diagnostic Imaging
- Gastroenterology
Background:
- Hepatolithiasis involves stones in the hepatic ducts, presenting diverse clinical scenarios from asymptomatic to life-threatening.
- Accurate diagnosis is vital for prognosis, with magnetic resonance cholangiopancreatography (MRCP) as the gold standard imaging modality.
- Atypical clinical and laboratory findings can complicate the diagnosis of hepatolithiasis.
Observation:
- A case of hepatolithiasis was initially misdiagnosed as choledocholithiasis due to incomplete MRCP reporting.
- Initial endoscopic intervention for presumed choledocholithiasis failed to resolve symptoms, leading to re-intervention.
- Recurrent cholangitis and subsequent CT imaging revealed intrahepatic bile duct dilatation, prompting re-evaluation.
Findings:
- Re-evaluation of initial and repeat MRCP confirmed hepatolithiasis, highlighting diagnostic challenges.
- Laparoscopic bisegmentectomy was successfully employed for definitive treatment of the intrahepatic stones.
- The patient experienced a full recovery and remained symptom-free during a 12-month follow-up period.
Implications:
- This case underscores the importance of thorough MRCP interpretation and re-evaluation in complex hepatobiliary cases.
- Diagnostic delays in hepatolithiasis can lead to complications like cholangitis, necessitating prompt and accurate diagnosis.
- Advanced surgical techniques like laparoscopic bisegmentectomy offer effective treatment for challenging hepatolithiasis cases.
Abstract:
Hepatolithiasis is a benign disease, where stones are localized proximal to the confluence of hepatic ducts. The clinical picture may differ depending on whether the stones cause complete, partial, or intermittent biliary obstruction. The course can vary from asymptomatic to fatal, thus, early diagnosis and treatment is critical for a good prognosis. The gold standard in imaging is magnetic resonance cholangiopancreatography (MRCP). However, correct diagnosis can be challenging due to atypical clinical picture and laboratory findings. We present a case where hepatolithiasis was misdiagnosed initially due to incomplete reporting and documentation of MRCP. Choledocholithiasis was diagnosed based on initial MRCP, and endoscopic stone extraction was indicated. However, an unusual post-interventional course and signs of obstructive cholangitis led to an endoscopic re-intervention, which confirmed absence of pathology in extrahepatic biliary ducts. The cholangitis recurrence required intensive antibiotic treatment, and CT examination revealed intrahepatic S3 bile duct dilatation. Thus, a re-evaluation of initial MRCP and repeated MRCP confirmed hepatolithiasis. Further, laparoscopic bisegmentectomy was chosen as the definitive treatment due to the location of the lesion. The patient recovered and remained symptom free upon a 12 month follow up.
