Molly G., an overweight, 47-year-old college administrator and mother of four, had been feeling healthy until recently. Then she regularly began to feel pain in the upper right quadrant of her abdomen. Sometimes the discomfort seemed to radiate around to her back and move upward into her right shoulder. Most commonly, she felt this pain after her evening meal; occasionally it also occurred during the night, awakening her. After an episode of particularly severe pain accompanied by sweating (diaphoresis) and nausea, Molly approached her physician.

During an examination of Molly's abdomen, the physician discovered tenderness in the epigastric region. She decided that Molly might be experiencing the symptoms of acute cholecystitis--an inflammation of the gallbladder. The physician recommended that Molly have a cholecystogram--an X ray of the gallbladder.

Molly took tablets containing a contrast medium the night before the X-ray procedure. This schedule allowed time for the small intestine to absorb the substance, which was carried to the liver and excreted into the bile. Later, the bile and contrast medium would be stored and concentrated in the gallbladder and would make the contents of the gallbladder opaque to X rays.

Molly's cholecystogram revealed several stones (calculi) in her gallbladder, a condition called cholelithiasis. Because Molly's symptoms of gallbladder disease were worsening, her physician recommended that she consult with an abdominal surgeon about undergoing a cholecystectomy--surgical removal of the gallbladder.

During the surgical procedure, an incision was made in Molly's right subcostal region. Her gallbladder was excised from the liver. Then the cystic duct and hepatic ducts were explored for the presence of stones, but none were found.

Unfortunately, following her recovery from surgery, Molly's symptoms persisted. Her surgeon ordered a cholangiogram--an X-ray series of the bile ducts. This study showed a residual stone at the distal end of Molly's common bile duct.

The surgeon extracted the residual stone using a fiberoptic endoscope, a long, flexible tube that can be passed through the patient's esophagus and stomach and into the duodenum. This instrument enables a surgeon to observe features of the gastrointestinal tract by viewing them directly through the eyepiece of the endoscope or by watching an image on the screen of a television monitor. A surgeon can also perform manipulations using specialized tools that are passed through the endoscope to its distal end.

In Molly's case, the surgeon performed an endoscopic papillotomy--an incision of the hepatopancreatic sphincter. This was done by applying an electric current to a wire extending from the end of the endoscope. He then removed the exposed stone by manipulating a tiny basket at the tip of the endoscope.

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