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Patient Profile
Patient Name
Mr. Ramesh Kulkarni
Age / Gender
62 Years / Male
Consultant
Dr. Vipulroy Dayanand Rathod
Hospital
Fortis Hospitals Limited, Mulund, Mumbai
Diagnosis
Choledocholithiasis with a Large Obstructing Common Bile Duct Stone
Past History
Gallstone disease · Prior cholecystectomy · Recurrent jaundice and biliary colic
Patient Background
Mr. Ramesh Kulkarni, a 62-year-old retired schoolteacher from Nashik, Maharashtra, presented to Fortis Hospital Mulund with progressive jaundice, itching, and recurrent right upper abdominal pain. He had undergone gallbladder removal several years earlier, but a large stone had migrated into and lodged within his common bile duct. Imaging revealed a stone too large to be cleared by standard ERCP basket or balloon extraction. Surgical exploration of the bile duct was suggested at another centre. Seeking an alternative to open surgery, his family looked for the Best Gastroenterologist In Mumbai for advanced biliary endoscopy. Dr. Vipulroy Rathod, Director of Gastroenterology at Fortis Mulund and South Asia’s pioneer of Endoscopic Ultrasound with over 20,000 EUS procedures, recommended ERCP with biliary stone extraction and cholangioscopy-guided lithotripsy to fragment and remove the giant stone entirely through the endoscope.
Symptoms
Obstructive jaundice — progressive yellowing of the eyes and skin over three weeks
Severe itching (pruritus) — due to bile salt accumulation, disturbing sleep
Recurrent biliary colic — right upper abdominal pain radiating to the back
Dark urine and pale stools — classic signs of biliary obstruction
Episodes of fever with chills — suggestive of early cholangitis
Diagnostic Method
Liver function tests
markedly raised bilirubin and obstructive pattern of liver enzymes
Ultrasound abdomen
dilated common bile duct with a large echogenic stone
MRCP
confirmed a single large (approximately 22 mm) impacted stone in the distal common bile duct with upstream ductal dilatation
Endoscopic Ultrasound (EUS)
high-resolution confirmation of stone size, location, and duct diameter to plan the approach
Pre-procedure evaluation
fitness for advanced endoscopic intervention assessed and confirmed
Disease Diagnosed
Mr. Kulkarni was diagnosed with choledocholithiasis — a large, impacted stone obstructing the common bile duct. The stone was too large for conventional extraction using a standard basket or balloon, and the obstruction was causing worsening jaundice with a risk of life-threatening cholangitis. As a gastroenterology specialist for complex biliary disease, Dr. Rathod identified ERCP with cholangioscopy-guided lithotripsy as the safest and most effective way to fragment and clear the stone without surgery.
Risks if Left Untreated:
Acute cholangitis
a potentially fatal infection of the obstructed bile duct
Secondary biliary cirrhosis from prolonged obstruction
Acute biliary pancreatitis if the stone migrated
Need for major open bile duct surgery with extended recovery
Treatment Plan
Dr. Vipulroy Rathod performed ERCP-based biliary stone extraction with Spyglass cholangioscopy and intraductal lithotripsy, directly visualising the stone inside the bile duct and fragmenting it into pieces small enough to be removed completely through the endoscope.
Why Endoscopic Removal Was Chosen Over Surgery
01 — No Surgical Incision
The entire stone is removed through the endoscope. No abdominal opening, no surgical wound, and no exploration of the bile duct.
02 — Direct Visualisation
Cholangioscopy allows the stone to be seen directly inside the duct, so lithotripsy energy is delivered precisely and the duct is confirmed clear at the end.
03 — Definitive Single-Session Clearance
Even very large or impacted stones can be fragmented and fully cleared, resolving the obstruction at its root rather than partially.
04 — Faster Recovery
Hours of recovery instead of weeks. Most patients go home within a day, compared to one to two weeks after open bile duct surgery.
How the Procedure Was Performed
- ERCP and cannulation — a side-viewing duodenoscope was passed to the duodenum and the common bile duct was selectively cannulated.
- Cholangiogram — contrast injection confirmed the large, impacted stone and mapped the biliary anatomy and degree of dilatation.
- Sphincterotomy and balloon dilatation — the biliary opening was widened with a controlled sphincterotomy and papillary balloon dilatation to allow stone clearance.
- Cholangioscopy (SpyGlass) — a single-operator cholangioscope was advanced into the bile duct for direct, real-time visualisation of the stone.
- Intraductal lithotripsy — laser/electrohydraulic lithotripsy energy was applied under direct vision to fragment the giant stone into smaller pieces.
- Stone extraction — fragments were retrieved using extraction balloon and basket until the duct was confirmed completely clear.
- Stent placement — a plastic biliary stent was placed to ensure free drainage and protect the duct during healing.
Procedure Summary
Procedure | ERCP with Cholangioscopy-Guided Lithotripsy (Stone Fragmentation & Clearance) |
Stent | Plastic biliary stent for post-procedure drainage |
Duration | 90 minutes |
Sedation | Conscious sedation with anaesthesia support |
Hospital Stay | Overnight, discharged the following morning |
Doctor’s Quote
“When a bile duct stone is this large, families are often told the only option is open surgery to cut the duct and remove it. With cholangioscopy, we can see the stone directly inside the duct, break it into fragments with precise energy, and clear it completely — all through the endoscope. Mr. Kulkarni’s jaundice began settling within a day, and he went home the next morning without a single incision. For complex bile duct stones, this is the difference between major surgery and an overnight stay.”
Dr. Vipulroy Rathod, FASGE | Gastroenterologist in Mumbai | Director, Gastroenterology and Hepatobiliary Sciences, Fortis Hospital Mulund
Post-Procedure Guidelines
Clear liquids initially, advancing to a normal low-fat diet as tolerated
Watch for and promptly report fever, severe pain, or recurrent jaundice
Complete the prescribed course of antibiotics if started for cholangitis
Stent review at 4 to 6 weeks with imaging to confirm the duct is clear and plan stent removal
Follow-up with Dr. Vipulroy Rathod for liver function review and ongoing biliary care
Outcome
| Timepoint | Result |
|---|---|
| Within 24 hrs | Bile flow restored, jaundice and itching beginning to settle |
| Day 1 | Discharged from hospital, no wound care or surgical aftercare required |
| 1 Week | Jaundice resolving steadily, appetite returning, back to light activity |
| 1 Month | Liver function tests normalised, no pain, eating normally |
| 6 Weeks | Imaging confirmed a fully cleared bile duct; stent removed |
| 3 Months | Symptom-free with normal liver function, returned to full routine |
Long-Term Expectations
With the large stone completely cleared and the bile duct confirmed open, Mr. Kulkarni’s jaundice and pain have fully resolved, and his quality of life has been restored. The temporary stent was removed once duct clearance was confirmed. A low-fat diet, adequate hydration, and periodic liver function review will support his long-term biliary health, with prompt evaluation of any recurrence of jaundice or pain.
Patient Feedback
“I had turned yellow and could not sleep because of the itching. At another hospital I was told my bile duct would have to be opened surgically. Dr. Rathod removed the stone through a scope and the next morning I was already feeling better. Within weeks I was completely back to normal. I am deeply grateful.”
Ramesh Kulkarni, 62 | Nashik, Maharashtra“We were frightened by the idea of surgery at his age. Dr. Rathod explained everything calmly and gave us a safer path. The result has been wonderful — my husband is healthy and active again. We thank him with all our hearts.”
Mrs. Sunita Kulkarni, Patient’s Wife | Nashik, Maharashtra
