Case Presentation: A 72-year-old man with type 2 diabetes mellitus (noncompliant with metformin), hypertension, hyperlipidemia, and atherosclerosis presented with fatigue, weakness, and dizziness lasting 2 days. There was no known trigger for his symptoms. He denied abdominal pain, nausea, or vomiting. On review of systems, he endorsed 20-lb weight loss over 6 months, constipation, pale stool, and dark urine. Exam was notable only for hypertension and trace scleral icterus. There was no abdominal tenderness and a negative Murphy’s sign. Patient’s vitals were T36.6, Heart Rate 60, Respiratory Rate 16, Blood Pressure 144/82, SPO2 100%.Labs revealed AST 105 U/L, ALT 300 U/L, ALP 190 U/L, total bilirubin 7.4 mg/dL, glucose 357 mg/dL and A1c 12.5%. CT abdomen showed a 2.8-cm gallstone with suspected choledocholithiasis; MRCP confirmed multiple common bile duct (CBD) stones and cholelithiasis.He underwent laparoscopic cholecystectomy followed by ERCP with sphincterotomy and stone extraction. Despite initial improvement, bilirubin rose to 10.5 mg/dL with leukocytosis (18 K/µL), new abdominal pain, fever, scleral icterus, and altered mentation. Empiric antibiotics were initiated. Repeat CT showed biliary dilation concerning for acute cholangitis. A second ERCP removed residual CBD stones, performed ampullary dilation, and placed a biliary stent. After completion of the procedure and antibiotic course, his liver chemistry and leukocytosis normalized over 2 days. His diabetes was managed with insulin in hospital, and he was transitioned to an outpatient insulin regimen when discharged.
Discussion: Not all gallstones scream in pain—some hide behind hyperglycemia. While choledocholithiasis typically presents with right upper quadrant pain, nausea, vomiting, and jaundice, a subset of patients—particularly older adults with comorbidities such as diabetes mellitus, hypertension, or atherosclerosis—may harbor painless common bile duct (CBD) stones.¹ In these individuals, autonomic neuropathy and diminished visceral pain perception may mask biliary colic, while impaired gallbladder motility predisposes to stone formation.² If left untreated, CBD stones can progress to pancreatitis or cholangitis, and asymptomatic presentation increases the risk of delayed diagnosis.³ Moreover, diabetes itself impairs host immunity and may independently increase susceptibility to acute cholangitis.⁴This report highlights a case of painless choledocholithiasis in a patient with poorly controlled diabetes whose symptoms were more consistent with hyperglycemia. The patient’s abnormal liver chemistries, pale stool, and dark urine pointed to biliary obstruction, but his presenting symptoms of dizziness, fatigue, and unexpected weight loss were likely due to uncontrolled hyperglycemia. Hyperglycemia may have contributed to his progression to acute cholangitis. Compounding risk factors for developing cholelithiasis in this patient included diabetes mellitus, hyperlipidemia, and rapid weight loss.
Conclusions: Asymptomatic CBD stones are diagnostically challenging, highlighting the importance of thorough history-taking for subtle biliary signs.⁵,⁶ Clinicians should remain vigilant during review of systems to uncover symptoms patients may not readily volunteer (eg, pale stool). Blunted pain perception should be considered in diabetic and elderly patients, as untreated stones carry increased risk for pancreatitis and cholangitis.⁵