SHM Converge Scientific Abstract ePoster Gallery-Low Pain, High Sugar: A Case-Report of Painless Choledocholithiasis in Uncontrolled Diabetes

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This case report describes a 72-year-old man with uncontrolled type 2 diabetes who presented with fatigue, weakness, and lightheadedness rather than the classic symptoms of choledocholithiasis. Although he denied abdominal pain, nausea, and vomiting, review of systems revealed subtle biliary signs, including 20-pound weight loss, constipation, pale stool, and dark urine. Exam showed mild scleral icterus without abdominal tenderness. Labs demonstrated cholestatic liver injury and severe hyperglycemia (glucose 357 mg/dL, HbA1c 12.5%). CT and MRCP confirmed gallstones and multiple common bile duct stones.<br /><br />The report emphasizes that older adults with diabetes may have atypical or painless presentations because autonomic neuropathy and impaired visceral pain perception can blunt classic biliary colic. Poor diabetes control may also contribute to gallstone formation through impaired gallbladder motility and increase the risk of infection due to immune dysfunction.<br /><br />The patient initially improved after insulin therapy, laparoscopic cholecystectomy, and ERCP with sphincterotomy and stone extraction. However, two days later he deteriorated with rising bilirubin, leukocytosis, new abdominal pain, fever, worsening jaundice, and altered mental status, consistent with acute cholangitis. He was treated with empiric antibiotics and a second ERCP that removed residual stones, dilated the ampulla, and placed a biliary stent. He then rapidly improved, with normalization of liver tests, leukocytosis, and mental status.<br /><br />Overall, the case highlights that painless or minimally symptomatic common bile duct stones can be diagnostically challenging, especially in older adults with diabetes. Clinicians should maintain a high index of suspicion and use a careful review of systems to identify subtle clues such as pale stool or dark urine. Early recognition and intervention are critical to prevent severe complications such as cholangitis and pancreatitis.

Asset Subtitle

Vanessa Orbe

Meta Tag

Author List Vanessa Orbe

Category Clinical Vignettes

Concept Choledocholithiasis

Concept Common Bile Duct Obstruction

Concept Cholangitis

Concept Endoscopic Retrograde Cholangiopancreatography

Concept Stone Extraction

Distinguished Non-Finalist

Presenter Organization Penn State College of Medicine

Presenting Author Vanessa Orbe

Track Adult

Keywords

choledocholithiasis

type 2 diabetes

painless presentation

common bile duct stones

cholestatic liver injury

acute cholangitis

gallstones

ERCP

biliary stent

autonomic neuropathy

Choledocholithiasis

Common Bile Duct Obstruction

Cholangitis

Endoscopic Retrograde Cholangiopancreatography

Stone Extraction