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An 83 year old woman presented with a two week history of right upper quadrant pain, pale stools, dark urine, and itch. In the previous five years there had been two episodes of similar symptoms, ultrasound scan showing multiple gall bladder calculi. Past history included hypertension, type 2 diabetes mellitus, and obesity.
On examination she was not clinically icteric, apyrexic, but mildly tender in the right upper quadrant. Liver enzymes were obstructive, bilirubin 31 μmol/l (3–20 μmol/l), alkaline phosphatase 842 U/l (100–280 U/l), γ-glutamyltranspeptidase 778 U/l (5–50 U/l).
On ultrasound scan there were gallbladder stones and a dilated common bile duct of 11 mm. Endoscopic retrograde cholangiopancreatography revealed a large single calculus in the dilated common bile duct, unable to be extracted after spincterotomy.
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