ACUTE CHOLANGITIS AND BILIARY
PANCREATITIS SECONDARY TO LATE PRIMARY
CHOLEDOCHOLITHIASIS 40 YEARS AFTER OPEN
CHOLECYSTECTOMY: A CASE REPORT
COLANGITIS AGUDA Y PANCREATITIS BILIAR SECUNDARIAS A
COLEDOCOLITIASIS PRIMARIA TARDÍA 40 AÑOS DESPUÉS DE UNA
COLECISTECTOMÍA ABIERTA: REPORTE DE CASO
Osvaldo González Moreno
Hospital Universitario de Puebla, Mexico
Estefani M. Ruiz Vigueras
Hospital Universitario de Puebla, Mexico
Maria F. Ramirez Velasco
Francisco J.Sánchez Vázquez
Hospital Universitario de Puebla, Mexico
Cheryl Z. Díaz Barrientos
Hospital Universitario de Puebla, Mexico
José M. Espinoza González
Hospital Universitario de Puebla, Mexico
pág. 3445
DOI: https://doi.org/10.37811/cl_rcm.v10i3.24340
Acute Cholangitis and Biliary Pancreatitis Secondary to Late Primary
Choledocholithiasis 40 Years After Open Cholecystectomy: A Case
Report
Osvaldo González Moreno1
Osvaldo200802@outlook.com
https://orcid.org/0009-0006-0048-8490
Department of General Surgery
Hospital Universitario de Puebla
Puebla, Mexico
Estefani M. Ruiz Vigueras
mirosruiz99@gmail.com
https://orcid.org/0009-0005-1324-7736
Department of General Surgery
Hospital Universitario de Puebla
Puebla, Mexico
Maria F. Ramirez Velasco
mariafernandavelasco222@gmail.com
https://orcid.org/0009-0001-7640-0284
Department of General Surgery
Hospital Universitario de Puebla
Puebla, Mexico
Francisco J.Sánchez Vázquez
medico.francisco@gmail.com
https://orcid.org/0009-0009-8613-933X
Department of General Surgery
Hospital Universitario de Puebla
Puebla, Mexico
Cheryl Z. Díaz Barrientos
cher_zilahy@hotmail.com
https://orcid.org/0000-0003-3046-1185
Department of General Surgery
Hospital Universitario de Puebla
Puebla, Mexico
José M. Espinoza González
cega.endoscopia@gmail.com
https://orcid.org/0009-0005-1581-1898
Department of General Surgery
Hospital Universitario de Puebla
Puebla, Mexico
ABSTRACT
Primary common bile duct stones after cholecystectomy are uncommon and may present with
diagnostic uncertainty when they occur decades after surgery. A 75-year-old woman with diabetes,
hypertension, hypothyroidism, and open cholecystectomy 40 years earlier presented with severe
epigastric pain radiating in a belt-like pattern, fever, nausea, and bilious vomiting. Laboratory findings
showed leukocytosis, direct hyperbilirubinemia, cholestatic enzyme elevation, and elevated amylase
and lipase. Computed tomography demonstrated common bile duct dilation with abrupt distal tapering.
She was diagnosed with mild acute pancreatitis and moderate acute cholangitis. Endoscopic retrograde
cholangiopancreatography demonstrated a dilated biliary tree with two 8-millimeter filling defects;
sphincterotomy and balloon sweeps achieved extraction of two stones. She improved clinically and
biochemically and was discharged without post-procedure complications. This case highlights that
primary choledocholithiasis remains a relevant differential diagnosis even four decades after
cholecystectomy.
Keywords: choledocholithiasis, post-cholecystectomy, cholangitis, biliary pancreatitis, endoscopic
retrograde cholangiopancreatography
1 Autor principal
Correspondencia: Osvaldo200802@outlook.com
DOI: https://doi.org/10.37811/cl_rcm.v10i3.24340
Acute Cholangitis and Biliary Pancreatitis Secondary to Late Primary
Choledocholithiasis 40 Years After Open Cholecystectomy: A Case
Report
Osvaldo González Moreno1
Osvaldo200802@outlook.com
https://orcid.org/0009-0006-0048-8490
Department of General Surgery
Hospital Universitario de Puebla
Puebla, Mexico
Estefani M. Ruiz Vigueras
mirosruiz99@gmail.com
https://orcid.org/0009-0005-1324-7736
Department of General Surgery
Hospital Universitario de Puebla
Puebla, Mexico
Maria F. Ramirez Velasco
mariafernandavelasco222@gmail.com
https://orcid.org/0009-0001-7640-0284
Department of General Surgery
Hospital Universitario de Puebla
Puebla, Mexico
Francisco J.Sánchez Vázquez
medico.francisco@gmail.com
https://orcid.org/0009-0009-8613-933X
Department of General Surgery
Hospital Universitario de Puebla
Puebla, Mexico
Cheryl Z. Díaz Barrientos
cher_zilahy@hotmail.com
https://orcid.org/0000-0003-3046-1185
Department of General Surgery
Hospital Universitario de Puebla
Puebla, Mexico
José M. Espinoza González
cega.endoscopia@gmail.com
https://orcid.org/0009-0005-1581-1898
Department of General Surgery
Hospital Universitario de Puebla
Puebla, Mexico
ABSTRACT
Primary common bile duct stones after cholecystectomy are uncommon and may present with
diagnostic uncertainty when they occur decades after surgery. A 75-year-old woman with diabetes,
hypertension, hypothyroidism, and open cholecystectomy 40 years earlier presented with severe
epigastric pain radiating in a belt-like pattern, fever, nausea, and bilious vomiting. Laboratory findings
showed leukocytosis, direct hyperbilirubinemia, cholestatic enzyme elevation, and elevated amylase
and lipase. Computed tomography demonstrated common bile duct dilation with abrupt distal tapering.
She was diagnosed with mild acute pancreatitis and moderate acute cholangitis. Endoscopic retrograde
cholangiopancreatography demonstrated a dilated biliary tree with two 8-millimeter filling defects;
sphincterotomy and balloon sweeps achieved extraction of two stones. She improved clinically and
biochemically and was discharged without post-procedure complications. This case highlights that
primary choledocholithiasis remains a relevant differential diagnosis even four decades after
cholecystectomy.
Keywords: choledocholithiasis, post-cholecystectomy, cholangitis, biliary pancreatitis, endoscopic
retrograde cholangiopancreatography
1 Autor principal
Correspondencia: Osvaldo200802@outlook.com
pág. 3446
Colangitis Aguda y Pancreatitis Biliar Secundarias a Coledocolitiasis
Primaria Tardía 40 Años Después de una Colecistectomía Abierta:
Reporte de Caso
RESUMEN
Las litiasis primarias del colédoco después de una colecistectomía son poco frecuentes y pueden generar
incertidumbre diagnóstica cuando aparecen décadas después de la cirugía. Se presenta el caso de una
mujer de 75 años con diabetes, hipertensión, hipotiroidismo y antecedente de colecistectomía abierta
40 años antes, quien acudió por dolor epigástrico intenso con irradiación en cinturón, fiebre, náusea y
vómito biliar. Los estudios de laboratorio mostraron leucocitosis, hiperbilirrubinemia directa, elevación
de enzimas colestásicas y elevación de amilasa y lipasa. La tomografía computarizada demostró
dilatación del colédoco con afilamiento distal abrupto. Se diagnosticó pancreatitis aguda leve y
colangitis aguda moderada. La colangiopancreatografía retrógrada endoscópica evidenció dilatación de
la vía biliar con dos defectos de llenado de 8 milímetros; se realizó esfinterotomía y barridos con balón,
logrando la extracción de dos litos. La paciente presentó mejoría clínica y bioquímica, y fue egresada
sin complicaciones posteriores al procedimiento. Este caso destaca que la coledocolitiasis primaria
continúa siendo un diagnóstico diferencial relevante incluso cuatro décadas después de una
colecistectomía.
Palabras clave: coledocolitiasis, postcolecistectomía, cholangitis, pancreatitis biliar,
colangiopancreatografía retrógrada endoscópica
Artículo recibido 25 abril 2026
Aceptado para publicación: 25 mayo 2026
Colangitis Aguda y Pancreatitis Biliar Secundarias a Coledocolitiasis
Primaria Tardía 40 Años Después de una Colecistectomía Abierta:
Reporte de Caso
RESUMEN
Las litiasis primarias del colédoco después de una colecistectomía son poco frecuentes y pueden generar
incertidumbre diagnóstica cuando aparecen décadas después de la cirugía. Se presenta el caso de una
mujer de 75 años con diabetes, hipertensión, hipotiroidismo y antecedente de colecistectomía abierta
40 años antes, quien acudió por dolor epigástrico intenso con irradiación en cinturón, fiebre, náusea y
vómito biliar. Los estudios de laboratorio mostraron leucocitosis, hiperbilirrubinemia directa, elevación
de enzimas colestásicas y elevación de amilasa y lipasa. La tomografía computarizada demostró
dilatación del colédoco con afilamiento distal abrupto. Se diagnosticó pancreatitis aguda leve y
colangitis aguda moderada. La colangiopancreatografía retrógrada endoscópica evidenció dilatación de
la vía biliar con dos defectos de llenado de 8 milímetros; se realizó esfinterotomía y barridos con balón,
logrando la extracción de dos litos. La paciente presentó mejoría clínica y bioquímica, y fue egresada
sin complicaciones posteriores al procedimiento. Este caso destaca que la coledocolitiasis primaria
continúa siendo un diagnóstico diferencial relevante incluso cuatro décadas después de una
colecistectomía.
Palabras clave: coledocolitiasis, postcolecistectomía, cholangitis, pancreatitis biliar,
colangiopancreatografía retrógrada endoscópica
Artículo recibido 25 abril 2026
Aceptado para publicación: 25 mayo 2026
pág. 3447
INTRODUCTION
Common bile duct stones usually arise from migration of gallbladder stones, but stones detected two or
more years after cholecystectomy are generally classified as primary common bile duct stones [1]. Late
post-cholecystectomy choledocholithiasis is uncommon, and intervals approaching 40 years have only
rarely been described [2]. When obstruction occurs, the clinical spectrum may include jaundice, acute
cholangitis, and acute biliary pancreatitis. We report a case of late primary choledocholithiasis
presenting 40 years after open cholecystectomy with both moderate acute cholangitis and mild biliary
pancreatitis, successfully treated by endoscopic retrograde cholangiopancreatography.
CASE PRESENTATION
A 75-year-old woman presented to the emergency department with epigastric pain. Her symptoms
began 11 days before admission and worsened the day before evaluation, reaching 10/10 intensity with
belt-like radiation, unquantified fever, nausea, and five episodes of bilious vomiting. She denied
choluria and acholia. Her history included type 2 diabetes mellitus, arterial hypertension,
hypothyroidism, and open cholecystectomy 40 years earlier. She denied alcohol use, previous
pancreatitis, previous cholangitis, and previous endoscopic retrograde cholangiopancreatography.
On admission, she was hemodynamically stable and afebrile. Laboratory tests showed leukocytosis of
31.45 x 10^3 per microliter with 90% neutrophils and 36% bands, total bilirubin 3.99 milligrams per
deciliter, direct bilirubin 3.05 milligrams per deciliter, aspartate aminotransferase 307 units per liter,
alanine aminotransferase 345 units per liter, alkaline phosphatase 920 units per liter, gamma-glutamyl
transferase 95 units per liter, amylase 955 units per liter, and lipase 2112 units per liter. Triglycerides
were 99 milligrams per deciliter and calcium was 10 milligrams per deciliter. Contrast-enhanced
computed tomography showed common bile duct dilation up to 13 millimeters in the supraduodenal
portion and 9.2 millimeters in the intrapancreatic portion, with abrupt distal tapering and no visible
stones. Mild acute pancreatitis and moderate acute cholangitis were diagnosed according to the revised
Atlanta classification and Tokyo Guidelines 2018, respectively [3,4].
Her abdominal pain resolved after emergency department analgesia; therefore, early oral intake was
initiated as tolerated. Intravenous hydration was started without an initial bolus using lactated
Ringer/Hartmann solution at 1.5 milliliters per kilogram per hour, approximately 86 milliliters per hour
INTRODUCTION
Common bile duct stones usually arise from migration of gallbladder stones, but stones detected two or
more years after cholecystectomy are generally classified as primary common bile duct stones [1]. Late
post-cholecystectomy choledocholithiasis is uncommon, and intervals approaching 40 years have only
rarely been described [2]. When obstruction occurs, the clinical spectrum may include jaundice, acute
cholangitis, and acute biliary pancreatitis. We report a case of late primary choledocholithiasis
presenting 40 years after open cholecystectomy with both moderate acute cholangitis and mild biliary
pancreatitis, successfully treated by endoscopic retrograde cholangiopancreatography.
CASE PRESENTATION
A 75-year-old woman presented to the emergency department with epigastric pain. Her symptoms
began 11 days before admission and worsened the day before evaluation, reaching 10/10 intensity with
belt-like radiation, unquantified fever, nausea, and five episodes of bilious vomiting. She denied
choluria and acholia. Her history included type 2 diabetes mellitus, arterial hypertension,
hypothyroidism, and open cholecystectomy 40 years earlier. She denied alcohol use, previous
pancreatitis, previous cholangitis, and previous endoscopic retrograde cholangiopancreatography.
On admission, she was hemodynamically stable and afebrile. Laboratory tests showed leukocytosis of
31.45 x 10^3 per microliter with 90% neutrophils and 36% bands, total bilirubin 3.99 milligrams per
deciliter, direct bilirubin 3.05 milligrams per deciliter, aspartate aminotransferase 307 units per liter,
alanine aminotransferase 345 units per liter, alkaline phosphatase 920 units per liter, gamma-glutamyl
transferase 95 units per liter, amylase 955 units per liter, and lipase 2112 units per liter. Triglycerides
were 99 milligrams per deciliter and calcium was 10 milligrams per deciliter. Contrast-enhanced
computed tomography showed common bile duct dilation up to 13 millimeters in the supraduodenal
portion and 9.2 millimeters in the intrapancreatic portion, with abrupt distal tapering and no visible
stones. Mild acute pancreatitis and moderate acute cholangitis were diagnosed according to the revised
Atlanta classification and Tokyo Guidelines 2018, respectively [3,4].
Her abdominal pain resolved after emergency department analgesia; therefore, early oral intake was
initiated as tolerated. Intravenous hydration was started without an initial bolus using lactated
Ringer/Hartmann solution at 1.5 milliliters per kilogram per hour, approximately 86 milliliters per hour
pág. 3448
based on an adjusted body weight of 57 kilograms, following a moderate goal-directed strategy aligned
with the WATERFALL protocol and contemporary acute pancreatitis guidance [9-11]. After clinical
improvement, preserved urine output, and adequate oral tolerance, the infusion rate was decreased to
57 milliliters per hour the next day. Because she remained hemodynamically stable, antimicrobial
therapy was started with ceftriaxone plus metronidazole while endoscopic source control was arranged.
She also received gastric protection and glycemic control.
Endoscopic retrograde cholangiopancreatography was performed on May 4, 2026. The common bile
duct was dilated to 10 millimeters. Endosonographic assessment identified an 8-millimeter stone, and
cholangiography showed intrahepatic and extrahepatic biliary dilation with two 8-millimeter filling
defects. Biliary cannulation was achieved with a sphincterotome and hydrophilic guidewire.
Sphincterotomy was performed, followed by balloon catheter sweeps with extraction of two stones.
Final fluoroscopy showed adequate drainage of contrast into the duodenum. The procedure lasted 23
minutes and was completed without apparent complications.
The patient improved clinically and biochemically. On May 5, she tolerated oral diet, had preserved
urine output, passed flatus, and had no abdominal pain or peritoneal signs. White blood cell count
decreased to 11.0 x 10^3 per microliter, total bilirubin to 0.8 milligrams per deciliter, direct bilirubin to
0.6 milligrams per deciliter, aspartate aminotransferase to 56 units per liter, and alanine
aminotransferase to 142 units per liter. No bleeding, perforation, or pancreatitis after endoscopic
retrograde cholangiopancreatography was documented. She was discharged after two days of
hospitalization with oral antimicrobial therapy, and outpatient follow-up was scheduled at three weeks.
DISCUSSION
This case illustrates a delayed biliopancreatic presentation of presumed primary choledocholithiasis
four decades after open cholecystectomy. The long interval, absence of previous biliary events, lack of
prior endoscopic retrograde cholangiopancreatography, and endoscopic confirmation of two bile duct
stones support primary ductal stone formation rather than retained stones. The main limitation is the
absence of stone composition analysis; therefore, the diagnosis is based on timing, clinical context, and
endoscopic findings rather than biochemical stone characterization.
based on an adjusted body weight of 57 kilograms, following a moderate goal-directed strategy aligned
with the WATERFALL protocol and contemporary acute pancreatitis guidance [9-11]. After clinical
improvement, preserved urine output, and adequate oral tolerance, the infusion rate was decreased to
57 milliliters per hour the next day. Because she remained hemodynamically stable, antimicrobial
therapy was started with ceftriaxone plus metronidazole while endoscopic source control was arranged.
She also received gastric protection and glycemic control.
Endoscopic retrograde cholangiopancreatography was performed on May 4, 2026. The common bile
duct was dilated to 10 millimeters. Endosonographic assessment identified an 8-millimeter stone, and
cholangiography showed intrahepatic and extrahepatic biliary dilation with two 8-millimeter filling
defects. Biliary cannulation was achieved with a sphincterotome and hydrophilic guidewire.
Sphincterotomy was performed, followed by balloon catheter sweeps with extraction of two stones.
Final fluoroscopy showed adequate drainage of contrast into the duodenum. The procedure lasted 23
minutes and was completed without apparent complications.
The patient improved clinically and biochemically. On May 5, she tolerated oral diet, had preserved
urine output, passed flatus, and had no abdominal pain or peritoneal signs. White blood cell count
decreased to 11.0 x 10^3 per microliter, total bilirubin to 0.8 milligrams per deciliter, direct bilirubin to
0.6 milligrams per deciliter, aspartate aminotransferase to 56 units per liter, and alanine
aminotransferase to 142 units per liter. No bleeding, perforation, or pancreatitis after endoscopic
retrograde cholangiopancreatography was documented. She was discharged after two days of
hospitalization with oral antimicrobial therapy, and outpatient follow-up was scheduled at three weeks.
DISCUSSION
This case illustrates a delayed biliopancreatic presentation of presumed primary choledocholithiasis
four decades after open cholecystectomy. The long interval, absence of previous biliary events, lack of
prior endoscopic retrograde cholangiopancreatography, and endoscopic confirmation of two bile duct
stones support primary ductal stone formation rather than retained stones. The main limitation is the
absence of stone composition analysis; therefore, the diagnosis is based on timing, clinical context, and
endoscopic findings rather than biochemical stone characterization.
pág. 3449
Primary duct stones are often linked to biliary stasis, ductal dilation, infection, advanced age, and altered
biliary drainage [1,5]. In this patient, the presentation was clinically important because obstruction
produced simultaneous acute cholangitis and biliary pancreatitis. The Tokyo Guidelines support early
severity assessment and source control in acute cholangitis [4,6], while American Society for
Gastrointestinal Endoscopy guidance supports endoscopic retrograde cholangiopancreatography as a
therapeutic modality for choledocholithiasis, particularly when cholangitis is present [8]. The favorable
response after sphincterotomy and balloon extraction, including rapid fall in leukocytes and bilirubin,
confirms effective biliary decompression.
Fluid management was relevant because the patient had mild acute pancreatitis and advanced age with
initial renal dysfunction. A moderate, goal-directed lactated Ringer strategy was selected without a
bolus. This approach is supported by the WATERFALL study protocol and the final randomized trial,
which compared early weight-based aggressive resuscitation with moderate goal-directed resuscitation
and found that aggressive resuscitation increased fluid overload without improving clinical outcomes
[9,10]. The 2024 American College of Gastroenterology guideline for acute pancreatitis also supports
moderately aggressive fluid resuscitation with reassessment, reserving additional boluses for evidence
of hypovolemia, and endorses early oral feeding in mild acute pancreatitis once tolerated [11].
Antimicrobial selection was also relevant from a stewardship perspective. Tokyo Guidelines 2018
recommend tailoring empirical therapy according to severity grade, acquisition setting, resistant-
organism risk, and local susceptibility patterns; broad antipseudomonal therapy such as
piperacillin/tazobactam is included among appropriate options but is not required in every
hemodynamically stable, community-acquired case [7]. In this patient, marked leukocytosis alone did
not mandate initial piperacillin/tazobactam because she had hemodynamic stability and prompt
endoscopic decompression was planned. Ceftriaxone plus metronidazole was selected as empirical
therapy, followed by definitive source control through sphincterotomy and extraction of both stones.
After source control, the leukocyte count decreased rapidly from 31.45 to 11.0 x 10^3 per microliter,
cholestatic parameters improved, and the patient was discharged on the second hospital day with oral
antimicrobial therapy, without the need to escalate to piperacillin/tazobactam or complete an extended
inpatient antimicrobial course.
Primary duct stones are often linked to biliary stasis, ductal dilation, infection, advanced age, and altered
biliary drainage [1,5]. In this patient, the presentation was clinically important because obstruction
produced simultaneous acute cholangitis and biliary pancreatitis. The Tokyo Guidelines support early
severity assessment and source control in acute cholangitis [4,6], while American Society for
Gastrointestinal Endoscopy guidance supports endoscopic retrograde cholangiopancreatography as a
therapeutic modality for choledocholithiasis, particularly when cholangitis is present [8]. The favorable
response after sphincterotomy and balloon extraction, including rapid fall in leukocytes and bilirubin,
confirms effective biliary decompression.
Fluid management was relevant because the patient had mild acute pancreatitis and advanced age with
initial renal dysfunction. A moderate, goal-directed lactated Ringer strategy was selected without a
bolus. This approach is supported by the WATERFALL study protocol and the final randomized trial,
which compared early weight-based aggressive resuscitation with moderate goal-directed resuscitation
and found that aggressive resuscitation increased fluid overload without improving clinical outcomes
[9,10]. The 2024 American College of Gastroenterology guideline for acute pancreatitis also supports
moderately aggressive fluid resuscitation with reassessment, reserving additional boluses for evidence
of hypovolemia, and endorses early oral feeding in mild acute pancreatitis once tolerated [11].
Antimicrobial selection was also relevant from a stewardship perspective. Tokyo Guidelines 2018
recommend tailoring empirical therapy according to severity grade, acquisition setting, resistant-
organism risk, and local susceptibility patterns; broad antipseudomonal therapy such as
piperacillin/tazobactam is included among appropriate options but is not required in every
hemodynamically stable, community-acquired case [7]. In this patient, marked leukocytosis alone did
not mandate initial piperacillin/tazobactam because she had hemodynamic stability and prompt
endoscopic decompression was planned. Ceftriaxone plus metronidazole was selected as empirical
therapy, followed by definitive source control through sphincterotomy and extraction of both stones.
After source control, the leukocyte count decreased rapidly from 31.45 to 11.0 x 10^3 per microliter,
cholestatic parameters improved, and the patient was discharged on the second hospital day with oral
antimicrobial therapy, without the need to escalate to piperacillin/tazobactam or complete an extended
inpatient antimicrobial course.
pág. 3450
Current guidance supports limiting antimicrobial duration to 4 to 7 days once biliary source control has
been achieved, with longer courses reserved for selected situations such as specific bacteremia patterns
or persistent anatomic problems [7].
CONCLUSION
Primary choledocholithiasis should remain in the differential diagnosis of biliary obstruction,
cholangitis, and pancreatitis even decades after cholecystectomy. In elderly post-cholecystectomy
patients, early biliary imaging and therapeutic endoscopic retrograde cholangiopancreatography can
provide definitive diagnosis, source control, and rapid clinical improvement.
Declarations
Informed consent: Written informed consent was obtained from the patient for publication of this case
report and the accompanying de-identified images.
Ethical approval: Institutional requirements should be verified before submission; single anonymized
case reports are commonly exempt, but local confirmation is recommended.
Competing interests: The authors declare no competing interests.
Funding: No external funding was received.
Author contributions: Osvaldo González Moreno contributed to diagnosis, treatment, data collection,
and manuscript conceptualization. Estefani Miroslava Ruiz Vigueras contributed to data collection and
manuscript drafting. Maria Fernanda Ramirez Velasco contributed to data collection. Francisco Javier
Sánchez Vázquez contributed to clinical follow-up and data collection. Cheryl Zilahy Díaz Barrientos
contributed to critical revision and final approval of the manuscript. José Miguel Espinoza González
performed the endoscopic retrograde cholangiopancreatography and contributed procedural data. All
authors reviewed and approved the final manuscript.
Data availability: All relevant clinical data are included in the article. Additional data are not publicly
available to protect patient confidentiality.
Current guidance supports limiting antimicrobial duration to 4 to 7 days once biliary source control has
been achieved, with longer courses reserved for selected situations such as specific bacteremia patterns
or persistent anatomic problems [7].
CONCLUSION
Primary choledocholithiasis should remain in the differential diagnosis of biliary obstruction,
cholangitis, and pancreatitis even decades after cholecystectomy. In elderly post-cholecystectomy
patients, early biliary imaging and therapeutic endoscopic retrograde cholangiopancreatography can
provide definitive diagnosis, source control, and rapid clinical improvement.
Declarations
Informed consent: Written informed consent was obtained from the patient for publication of this case
report and the accompanying de-identified images.
Ethical approval: Institutional requirements should be verified before submission; single anonymized
case reports are commonly exempt, but local confirmation is recommended.
Competing interests: The authors declare no competing interests.
Funding: No external funding was received.
Author contributions: Osvaldo González Moreno contributed to diagnosis, treatment, data collection,
and manuscript conceptualization. Estefani Miroslava Ruiz Vigueras contributed to data collection and
manuscript drafting. Maria Fernanda Ramirez Velasco contributed to data collection. Francisco Javier
Sánchez Vázquez contributed to clinical follow-up and data collection. Cheryl Zilahy Díaz Barrientos
contributed to critical revision and final approval of the manuscript. José Miguel Espinoza González
performed the endoscopic retrograde cholangiopancreatography and contributed procedural data. All
authors reviewed and approved the final manuscript.
Data availability: All relevant clinical data are included in the article. Additional data are not publicly
available to protect patient confidentiality.
pág. 3451
Table 1. Clinical timeline
Date or period Clinical event
40 years before admission Open cholecystectomy.
April 22, 2026 Onset of punctate epigastric pain.
May 2, 2026 Pain worsened to 10/10 with belt-like radiation, fever, nausea, and
bilious vomiting.
May 3, 2026 Admission; mild acute pancreatitis, moderate acute cholangitis, and
suspected choledocholithiasis.
May 4, 2026 Endoscopic retrograde cholangiopancreatography with
sphincterotomy and extraction of two 8-millimeter common bile
duct stones.
May 5, 2026 Clinical and biochemical improvement; discharge after two days of
hospitalization.
3 weeks after discharge Outpatient follow-up scheduled.
Table 2. Biochemical trend before and after endoscopic retrograde cholangiopancreatography
Parameter May 3, 2026 May 4, 2026 May 5, 2026
White blood cell count (x 10^3 per microliter) 31.45 17.24 11.0
Neutrophils (%) 90 91 88
Bands (%) 36 31 11
Total bilirubin (milligrams per deciliter) 3.99 2.99 0.8
Direct bilirubin (milligrams per deciliter) 3.05 1.83 0.6
Aspartate aminotransferase (units per liter) 307 154 56
Alanine aminotransferase (units per liter) 345 225 142
Alkaline phosphatase (units per liter) 920 684 591
Gamma-glutamyl transferase (units per liter) 95 733 628
Amylase (units per liter) 955 Not reported Not reported
Lipase (units per liter) 2112 Not reported Not reported
Creatinine (milligrams per deciliter) 1.66 1.39 Not reported
Table 1. Clinical timeline
Date or period Clinical event
40 years before admission Open cholecystectomy.
April 22, 2026 Onset of punctate epigastric pain.
May 2, 2026 Pain worsened to 10/10 with belt-like radiation, fever, nausea, and
bilious vomiting.
May 3, 2026 Admission; mild acute pancreatitis, moderate acute cholangitis, and
suspected choledocholithiasis.
May 4, 2026 Endoscopic retrograde cholangiopancreatography with
sphincterotomy and extraction of two 8-millimeter common bile
duct stones.
May 5, 2026 Clinical and biochemical improvement; discharge after two days of
hospitalization.
3 weeks after discharge Outpatient follow-up scheduled.
Table 2. Biochemical trend before and after endoscopic retrograde cholangiopancreatography
Parameter May 3, 2026 May 4, 2026 May 5, 2026
White blood cell count (x 10^3 per microliter) 31.45 17.24 11.0
Neutrophils (%) 90 91 88
Bands (%) 36 31 11
Total bilirubin (milligrams per deciliter) 3.99 2.99 0.8
Direct bilirubin (milligrams per deciliter) 3.05 1.83 0.6
Aspartate aminotransferase (units per liter) 307 154 56
Alanine aminotransferase (units per liter) 345 225 142
Alkaline phosphatase (units per liter) 920 684 591
Gamma-glutamyl transferase (units per liter) 95 733 628
Amylase (units per liter) 955 Not reported Not reported
Lipase (units per liter) 2112 Not reported Not reported
Creatinine (milligrams per deciliter) 1.66 1.39 Not reported
pág. 3452
Figure 1
De-identified endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography
procedural images. The study demonstrated biliary dilation and choledocholithiasis, followed by
guidewire cannulation, sphincterotomy, balloon sweeps, and extraction of a common bile duct stone.
BIBLIOGRÁPHIC REFERENCES
1. Mansour S, Kluger Y, Khuri S. Primary recurrent common bile duct stones: timing of surgical
intervention. J Clin Med Res. 2022;14(11):441-447. doi:10.14740/jocmr4826.
2. Ng B. Case report of choledocholithiasis 40 years post cholecystectomy. Radiol Case Rep.
2024;19(4):1589-1591. doi:10.1016/j.radcr.2024.01.025.
3. Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis--2012: revision of the
Atlanta classification and definitions by international consensus. Gut. 2013;62(1):102-111.
doi:10.1136/gutjnl-2012-302779.
4. Kiriyama S, Kozaka K, Takada T, et al. Tokyo Guidelines 2018: diagnostic criteria and severity
grading of acute cholangitis (with videos). J Hepatobiliary Pancreat Sci. 2018;25(1):17-30.
doi:10.1002/jhbp.512.
5. Wu Y, Xu CJ, Xu SF. Advances in risk factors for recurrence of common bile duct stones. Int J
Med Sci. 2021;18(4):1067-1074. doi:10.7150/ijms.52974.
6. Miura F, Okamoto K, Takada T, et al. Tokyo Guidelines 2018: initial management of acute biliary
infection and flowchart for acute cholangitis. J Hepatobiliary Pancreat Sci. 2018;25(1):31-40.
doi:10.1002/jhbp.509.
Figure 1
De-identified endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography
procedural images. The study demonstrated biliary dilation and choledocholithiasis, followed by
guidewire cannulation, sphincterotomy, balloon sweeps, and extraction of a common bile duct stone.
BIBLIOGRÁPHIC REFERENCES
1. Mansour S, Kluger Y, Khuri S. Primary recurrent common bile duct stones: timing of surgical
intervention. J Clin Med Res. 2022;14(11):441-447. doi:10.14740/jocmr4826.
2. Ng B. Case report of choledocholithiasis 40 years post cholecystectomy. Radiol Case Rep.
2024;19(4):1589-1591. doi:10.1016/j.radcr.2024.01.025.
3. Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis--2012: revision of the
Atlanta classification and definitions by international consensus. Gut. 2013;62(1):102-111.
doi:10.1136/gutjnl-2012-302779.
4. Kiriyama S, Kozaka K, Takada T, et al. Tokyo Guidelines 2018: diagnostic criteria and severity
grading of acute cholangitis (with videos). J Hepatobiliary Pancreat Sci. 2018;25(1):17-30.
doi:10.1002/jhbp.512.
5. Wu Y, Xu CJ, Xu SF. Advances in risk factors for recurrence of common bile duct stones. Int J
Med Sci. 2021;18(4):1067-1074. doi:10.7150/ijms.52974.
6. Miura F, Okamoto K, Takada T, et al. Tokyo Guidelines 2018: initial management of acute biliary
infection and flowchart for acute cholangitis. J Hepatobiliary Pancreat Sci. 2018;25(1):31-40.
doi:10.1002/jhbp.509.
pág. 3453
7. Gomi H, Solomkin JS, Schlossberg D, et al. Tokyo Guidelines 2018: antimicrobial therapy for acute
cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25(1):3-16.
doi:10.1002/jhbp.518.
8. Buxbaum JL, Abbas Fehmi SM, Sultan S, et al. ASGE guideline on the role of endoscopy in the
evaluation and management of choledocholithiasis. Gastrointest Endosc. 2019;89(6):1075-
1105.e15. doi:10.1016/j.gie.2018.10.001.
9. Bolado F, Buxbaum JL, Vaillo-Rocamora A, Cárdenas-Jaén K, Maisonneuve P, de-Madaria E.
Early weight-based aggressive vs. non-aggressive goal-directed fluid resuscitation in the early
phase of acute pancreatitis: an open-label multicenter randomized controlled trial (the
WATERFALL trial), design, and rationale. Front Med (Lausanne). 2020;7:440.
doi:10.3389/fmed.2020.00440.
10. de-Madaria E, Buxbaum JL, Maisonneuve P, et al. Aggressive or moderate fluid resuscitation in
acute pancreatitis. N Engl J Med. 2022;387(11):989-1000. doi:10.1056/NEJMoa2202884.
11. Tenner S, Vege SS, Sheth SG, Sauer B, Yang A, Conwell DL, et al. American College of
Gastroenterology Guidelines: Management of Acute Pancreatitis. Am J Gastroenterol.
2024;119(3):419-437. doi:10.14309/ajg.0000000000002645.
12. International Association of Pancreatology and American Pancreatic Association Acute
Pancreatitis Guidelines Working Group. IAP/APA evidence-based guidelines for the management
of acute pancreatitis. Pancreatology. 2013;13(4 Suppl 2):e1-e15. doi:10.1016/j.pan.2013.07.063.
13. Sohrabi C, Mathew G, Maria N, Kerwan A, Franchi T, Agha RA. The SCARE 2023 guideline:
updating consensus Surgical Case Report guidelines. Int J Surg. 2023;109(5):1136-1140.
doi:10.1097/JS9.0000000000000373.
14. Gagnier JJ, Kienle G, Altman DG, Moher D, Sox H, Riley D; CARE Group. The CARE guidelines:
consensus-based clinical case reporting guideline development. J Clin Epidemiol. 2014;67(1):46-
51. doi:10.1016/j.jclinepi.2013.08.003.
7. Gomi H, Solomkin JS, Schlossberg D, et al. Tokyo Guidelines 2018: antimicrobial therapy for acute
cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25(1):3-16.
doi:10.1002/jhbp.518.
8. Buxbaum JL, Abbas Fehmi SM, Sultan S, et al. ASGE guideline on the role of endoscopy in the
evaluation and management of choledocholithiasis. Gastrointest Endosc. 2019;89(6):1075-
1105.e15. doi:10.1016/j.gie.2018.10.001.
9. Bolado F, Buxbaum JL, Vaillo-Rocamora A, Cárdenas-Jaén K, Maisonneuve P, de-Madaria E.
Early weight-based aggressive vs. non-aggressive goal-directed fluid resuscitation in the early
phase of acute pancreatitis: an open-label multicenter randomized controlled trial (the
WATERFALL trial), design, and rationale. Front Med (Lausanne). 2020;7:440.
doi:10.3389/fmed.2020.00440.
10. de-Madaria E, Buxbaum JL, Maisonneuve P, et al. Aggressive or moderate fluid resuscitation in
acute pancreatitis. N Engl J Med. 2022;387(11):989-1000. doi:10.1056/NEJMoa2202884.
11. Tenner S, Vege SS, Sheth SG, Sauer B, Yang A, Conwell DL, et al. American College of
Gastroenterology Guidelines: Management of Acute Pancreatitis. Am J Gastroenterol.
2024;119(3):419-437. doi:10.14309/ajg.0000000000002645.
12. International Association of Pancreatology and American Pancreatic Association Acute
Pancreatitis Guidelines Working Group. IAP/APA evidence-based guidelines for the management
of acute pancreatitis. Pancreatology. 2013;13(4 Suppl 2):e1-e15. doi:10.1016/j.pan.2013.07.063.
13. Sohrabi C, Mathew G, Maria N, Kerwan A, Franchi T, Agha RA. The SCARE 2023 guideline:
updating consensus Surgical Case Report guidelines. Int J Surg. 2023;109(5):1136-1140.
doi:10.1097/JS9.0000000000000373.
14. Gagnier JJ, Kienle G, Altman DG, Moher D, Sox H, Riley D; CARE Group. The CARE guidelines:
consensus-based clinical case reporting guideline development. J Clin Epidemiol. 2014;67(1):46-
51. doi:10.1016/j.jclinepi.2013.08.003.