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Obstructive jaundice occur mostly secondry to stone diseases or malignancies. Malignancies are important causes and are often unresectable at the time of diagnosis [1]. Although rare, the possibilities for the co-existence of other benign causes need to be considered as the treatment required will be different [2]. Periampullary cancers include a group of malignant neoplasms arising in the pancreas or in or near the ampulla of Vater [3]. They usually present with obstructive jaundice or pain. Objective imaging tests, such as computed tomography, ultrasonography and/or endoscopic retrograde cholangio-pancreatography, should be performed in all patients to rule out causes other than malignancy. Potential errors in judgement may be avoided by a more aggressive attempt at biopsy in selected patients. Because of a high incidence of concurrent cholelithiasis, many patients with a periampullary carcinoma seen during ERCP are misdiagnosed earlier (by clinical evaluation and non-invasive imaging) as having choledocholithiasis. However, here we present a case where the converse came true.

A 40 year old female presented with pain in right upper abdomen for last 6 months associated with fever. There was no history of jaundice, loss of appetite, weight loss, bowel or bladder disturbances. She had a past history of palliative triple bypass for advanced periampullary carcinoma diagnosed after an episode of obstructive jaundice 3 years back. On examination, she had hepatomegaly. Biochemical parameters and liver function tests were found to be normal.

Ultrasound showed gallstones in CBD with air in intra hepatic biliary radicals. CT showed dilated CBD, dilated intra hepatic biliary radicals (IHBR), with air collection predominant on left lobe of liver. MRI showed dilated CBD with few calculi, 2 prominent stones in proximal and distal CBD measuring 1.5 x 1.1 mm and 1.5 x 0.9 mm respectively other two measured 7 mm and 5 mm each, CBD measured 15 mm, right hepatic duct- 8 mm & left hepatic duct-10 mm [Fig.1].

On surgical exploration, cholecystojejunostomy was noted. Cholecystectomy & choledochotomy was done, stones removed and CBD closed on a T-tube. Pancreas was found to be normal. On 15th post-operative day, T-tube cholangiogram showed filling defect in distal CBD. On 23rd post-operative day, ERCP showed filling defect in distal CBD, 1.5 cm stone in distal CBD, which was removed later by ERCP. Patient improved symptomatically with no recurrence reported on 6 months of follow up [Fig.2].

About 8-15 per cent of patients with symptomatic gallstones may have associated common bile duct (CBD) stones [4]. In order to predict the presence of bile duct stones more accurately, the combination of clinical, laboratory, and ultrasound risk factors has been used by several investigators.

A  pre-ERCP  diagnosis (by clinical evaluation and non-invasive imaging)  of  tumor  versus  choledocholithiasis  was  accurate  in only  65% [5]. ERCP has long been considered the standard reference for the establishment of common bile duct stones with sensitivity of 90% and specificity of 98%, with a 96% accuracy.  ERCP has the advantage of offering therapeutic intervention options in the same setting of diagnosis. While MRCP has a sensitivity and specificity of 96% and 86% for CBD stone diagnosis, it offers no therapeutic advantage [6].

In our present case, common bile duct calculi were inadvertently diagnosed as an advanced malignancy and operated upon. Ultrasound has a high specificity in the detection of common bile duct calculi although occasionally non-echogenic calculi at the lower end of the common bile duct can be missed or misinterpreted as a pancreatic mass [7]. Endoscopic ultrasonography offers high resolution imaging of the pancreas without intervening bowel gas, and excellent mucosal definintion in the duodenum [8]. ERCP offers the potential both for accurate tissue diagnosis and for therapy, and we suggest that a stone impacted at the lower end of the common bile duct should be considered, even in an asymptomatic patient, when a malignancy is suspected. 

Gallstones in CBD are an important and more common cause of surgical jaundice than periampullary carcinoma, though often under diagnosed. Thorough preoperative evaluation is of paramount importance. Failure or delay in the actual diagnosis may lead to a poorer outcome.

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