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case_images: (A) Coronal image of abdominal contrast-enhanced CT shows common hepatic duct stone (black arrow) and cystic duct stone (white arrow). (B) Another coronal image of abdominal contrast-enhanced CT shows common bile duct stone (arrowhead).
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case_images: Contrast-enhanced abdominal computed tomography (CT) showed multiple stones in the cystic duct, common hepatic duct, and common bile duct with biliary dilatation and duodenal parapapillary diverticulums (Figs. 1A and B).
case_images: (A) Coronal image of T2-weighted MRI shows common hepatic duct stone (black arrow) and cystic duct stone (white arrow). (B) Another coronal image of T2-weighted MRI shows cystic duct stone (white arrow) and common bile duct stone (arrowhead).
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case_images: The abdominal magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography (MRCP) also showed multiple stones of varying sizes (8, 17, and 14mm, respectively) in the cystic duct, common hepatic duct, and common bile duct (Figs. 2A and B).
case_images: (A) Initial percutaneous transhepatic cholangiogram shows a common hepatic large stone (black arrow). (B) The second cholangiogram via PTBD tube shows multiple stones in the cystic duct (white arrow), common hepatic duct (black arrow), and common bile duct (arrowhead).
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case_images: Initial percutaneous transhepatic cholangiography through the right anterior hepatic duct revealed a large stone in the common hepatic duct (Fig. 3A). A second cholangiogram through the PTBD tube revealed multiple stones in the cystic duct, common hepatic duct, and common bile duct (Fig. 3B).
case_images: (A) Balloon dilation of the papilla of Vater (black arrow). (B) Cholangiogram shows a removal balloon catheter (black arrow) covered with the sheath that pushes stones into the duodenum.
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case_images: The papilla of Vater was dilated with a balloon 12 mm in diameter for 10 minutes at 2 atm (Fig. 4A). Common hepatic and bile ducts stones were crushed by electrohydraulic lithotripsy (EHL) and then pushed out into the duodenum through the dilated papilla of Vater using a 6 Fr. balloon catheter covered with the sheath and cholangioscopy (Fig. 4B).
case_images: (A) Cholangiogram shows cystic duct stone (white arrow). (A*) Cholangioscopic picture shows cystic duct stone. (B) Cholangiogram shows a 5 Fr. balloon catheter and guidewire in the cystic duct (black arrow). (C) Cholangiogram shows that the balloon (black arrow) is inflated and the stone (white arrow) is pulled into the common bile duct. (D) Balloon-occluded cholangiogram using cobra-shaped sheath and 6Fr. balloon catheter shows clearance of cystic duct, common hepatic, and common bile duct stones. The contrast medium is injected through the sheath. An inflated balloon to occlude the dilated papilla of Vater is indicated by an arrow.
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case_images: The cystic duct stone was observable with a cholangioscope (Figs. 5A and A*), but the bending of the cholangioscope made it difficult to insert the EHL probe into the optimal position. For stone located in the cystic duct, a 5 Fr. balloon catheter was inserted into the cystic duct following a guidewire by using the cobra-shaped sheath (Fig. 5B). The balloon was inflated and the stone was pulled into the common bile duct (Fig. 5C). Clearance of cystic duct and bile duct stones was confirmed by balloon-occluded cholangiography using a cobra-shaped sheath and a 6 Fr. balloon catheter (Fig. 5D).
case_images: (A) MRCP 10 days after percutaneous stone removal shows no residual stone in the cystic duct (white arrow). (B) Repeated and final cholangiogram 10 days after percutaneous stone removal shows that the cystic duct, common hepatic, and common bile ducts are free of stones.
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case_images: Ten days after percutaneous stone removal, the PTBD tube was removed after confirming that the cystic duct, common hepatic, and common bile ducts were free of stones on MRCP and final cholangiography (Figs. 6A and B).