Gallstone cirrhosis: are we only seeing the tip of the iceberg?

Gallstones are common and their incidence increases with age. Fifty per cent of these stones are in the common bile duct (CBD) in the elderly. Most of them are silent but with time there is an increasing chance of developing symptoms which are more likely to be serious in the elderly. Failure to relieve mechanical obstruction of bile flow may lead to secondary biliary cirrhosis. It has been estimated that on average secondary biliary cirrhosis develops some seven years after the onset of obstruction from a stricture, four and half years after gallstone obstruction and 10 months after the onset of malignant stricture. The characteristic features are the pathological findings of portal-portal linkages, with a pattern of monolobular cirrhosis and the preservation of normal vascular relationships. Secondary biliary cirrhosis may lead to hepatic insufficiency and portal hypertension with the resultant complications, such as bleeding oesophageal varices, hypersplenism with pancytopenia, ascites and encephalopathy. We describe a patient in whom the diagnosis was not suspected until laparotomy and confirmed only at autopsy.