Choledocholithiasis: Causes, Symptoms, and Diagnosis
Approach to CBD stone
1
CHOLEDOCHOLITHIASIS
C
o
m
m
o
n
b
i
l
e
d
u
c
t
s
t
o
n
e
s
•
Small
or
large
•
single
or
multiple
•
Found
in 6% to
12%
of
patients
with
stones
in the
GB
•
The
incidence
increases with
age.
2
CHOLEDOCHOLITHIASIS
•
P
r
i
m
a
r
y
C
B
D
S
t
o
n
e
s
t
h
a
t
f
o
r
m
i
n
t
h
e
b
i
l
e
d
u
c
t
s
.
•
U
s
u
a
l
l
y
b
r
o
w
n
p
i
g
m
e
n
t
t
y
p
e
a
s
s
o
c
i
a
t
e
d
w
i
t
h
b
i
l
i
a
r
y
s
t
a
s
i
s
&
i
n
f
e
c
t
i
o
n
•
more commonly seen in Asian
populations.
•
The
causes
of
biliary
stasis that
lead
to the
development
of
primary
stones
include biliary
stricture,
papillary stenosis,
tumors,
or
other
(secondary
stones
)
.
•
S
e
c
o
n
d
a
r
y
C
B
D
s
t
o
n
e
s
:
f
o
r
m
e
d
w
i
t
h
i
n
t
h
e
g
a
l
l
b
l
a
d
d
e
r
m
i
g
r
a
t
e
d
o
w
n
t
h
e
cystic
duct
to
the common bile
duct.
•
u
s
u
a
l
l
y
c
h
o
l
e
s
t
e
r
o
l
s
t
o
n
e
s
3
CHOLEDOCHOLITHIASIS
•
C
L
I
N
I
C
A
L
M
A
N
I
F
E
S
T
A
T
I
O
N
S
•
S
I
L
E
N
T
,
o
f
t
e
n
d
i
s
c
o
v
e
r
e
d
i
n
c
i
d
e
n
t
a
l
l
y
.
•
may cause obstruction, complete
or
incomplete,
OR
•
may
manifest
with
cholangitis
or
gallstone
pancreatitis.
•
T
h
e
P
A
I
N
o
f
C
B
D
S
t
o
n
e
,
a
l
s
o
b
i
l
i
a
r
y
c
o
l
i
c
(
s
i
m
i
l
a
r
t
o
c
y
s
t
i
c
d
u
c
t
s
t
o
n
e
)
=
>
J
a
u
n
d
i
c
e
,
N
a
u
s
e
a
a
n
d
v
o
m
i
t
i
n
g
a
r
e
c
o
m
m
o
n
.
4
CHOLEDOCHOLITHIASIS
•
P
H
Y
S
I
C
A
L
E
X
A
M
I
N
A
T
I
O
N
•
m
a
y
b
e
n
o
r
m
a
l
,
b
u
t
m
i
l
d
e
p
i
g
a
s
t
r
i
c
o
r
R
U
Q
t
e
n
d
e
r
n
e
s
s
a
s
w
e
l
l
a
s
m
i
l
d
i
c
t
e
r
u
s
a
r
e
c
o
m
m
o
n
.
•
T
h
e
s
y
m
p
t
o
m
s
•
i
n
t
e
r
m
i
t
t
e
n
t
;
p
a
i
n
a
n
d
t
r
a
n
s
i
e
n
t
j
a
u
n
d
i
c
e
(
t
e
m
p
o
r
a
r
i
l
y
i
m
p
a
c
t
s
t
h
e
a
m
p
u
l
l
a
b
u
t
s
u
b
s
e
q
u
e
n
t
l
y
m
o
v
e
s
a
w
a
y
,
a
c
t
i
n
g
a
s
a
b
a
l
l
v
a
l
v
e
)
•
C
B
D
s
t
o
n
e
p
a
s
s
t
h
r
o
u
g
h
t
h
e
a
m
p
u
l
l
a
s
p
o
n
t
a
n
e
o
u
s
l
y
r
e
s
o
l
u
t
i
o
n
•
b
e
c
o
m
e
c
o
m
p
l
e
t
e
l
y
i
m
p
a
c
t
e
d
s
e
v
e
r
e
p
r
o
g
r
e
s
s
i
v
e
j
a
u
n
d
i
c
e
.
5
DIAGNOSTIC
STUDIES
R
O
U
T
I
N
E
B
l
o
o
d
T
e
s
t
s
:
•
1
-
C
B
C
•
I
n
c
r
e
a
s
e
d
W
B
C
:
r
a
i
s
e
s
u
s
p
i
c
i
o
n
o
f
C
H
O
L
E
C
Y
S
T
I
T
I
S
.
•
2
-
L
I
V
E
R
F
U
N
C
T
I
O
N
T
E
S
T
•
e
l
e
v
a
t
i
o
n
o
f
b
i
l
i
r
u
b
i
n
,
a
l
k
a
l
i
n
e
p
h
o
s
p
h
a
t
a
s
e
,
a
n
d
a
m
i
n
o
t
r
a
n
s
f
e
r
a
s
e
,
C
H
O
L
A
N
G
I
T
I
S
should be
suspected.
•
elevation
of
conjugated
bilirubi
n
and a rise in alkaline phosphatase
C
H
O
L
E
S
T
A
S
I
S
.
S
e
r
u
m
a
m
i
n
o
t
r
a
n
s
f
e
r
a
s
e
s
m
a
y
b
e
n
o
r
m
a
l
o
r
m
i
l
d
l
y
e
l
e
v
a
t
e
d
.
•
I
n
p
a
t
i
e
n
t
s
w
i
t
h
b
i
l
i
a
r
y
c
o
l
i
c
o
r
c
h
r
o
n
i
c
c
h
o
l
e
c
y
s
t
i
t
i
s
•
blood
tests
will typically be
normal.
6
INITIAL
INVESTIGATIONS
L
i
v
e
r
F
u
n
c
t
i
o
n
T
e
s
t
(
L
F
T
)
•
Completely normal: NPV >
97%
•
Abnormal:
PPV
15%
•
B
i
l
i
r
u
b
i
n
i
s
t
h
e
s
t
r
o
n
g
e
s
t
p
r
e
d
i
c
t
o
r
f
o
r
C
B
D
s
t
o
n
e
s
;
s
p
e
c
i
f
i
c
i
t
y
v
a
r
i
e
s
a
c
c
o
r
d
i
n
g
t
o
l
e
v
e
l
•
Bilirubin ≥
30
µmol/L: specificity
60%
•
Bilirubin ≥
68
µmol/L: specificity
75%
•
Mean bilirubin in CBD
stones:
25.5 – 32.3
µmol/L
7
DIAGNOSTIC
STUDIES
1
-
U
L
T
R
A
S
O
N
O
G
R
A
P
H
Y
A
d
v
a
n
t
a
g
e
s
:
•
Initial investigation
of
GBD
•
Noninvasive, painless, No radiation
exposure
•
can be performed on critically ill
patients.
•
Adjacent organs can frequently be examined
at the
same
time.
D
i
s
a
d
v
a
n
t
a
g
e
s
•
Operator
dependent
•
Not
satisfactory for
Obese
patients,
patients with
ascites &
distended
bowel
8
DIAGNOSTIC
STUDIES
•
U
L
T
R
A
S
O
N
O
G
R
A
P
H
Y
•
G
A
L
L
S
T
O
N
E
•
sensitivity
and specificity >90%)
•
dense, acoustic
shadow
•
Move with changes in
position
•
P
O
L
Y
P
S
•
may be calcified
reflect
shadows
•
do
not
move with change in
posture.
Acoustic shadows from gall
stones.
9
DIAGNOSIS
STUDIES
2
-
M
a
g
n
e
t
i
c
r
e
s
o
n
a
n
c
e
c
h
o
l
a
n
g
i
o
g
r
a
p
h
y
(
M
R
C
)
•
provides
excellent
anatomic
detail
•
sensitivity
and
specificity
of 95% and
89%
•
detecting choledocholithiasis
>5 mm in
diameter
3
-
E
n
d
o
s
c
o
p
i
c
c
h
o
l
a
n
g
i
o
g
r
a
p
h
y
(
E
R
C
)
•
G
O
L
D
S
T
A
N
D
A
R
D
F
O
R
D
I
A
G
N
O
S
I
N
G
C
O
M
M
O
N
B
I
L
E
D
U
C
T
S
T
O
N
E
S
.
•
d
i
s
t
i
n
c
t
a
d
v
a
n
t
a
g
e
:
T
H
E
R
A
P
E
U
T
I
C
O
P
T
I
O
N
a
t
t
h
e
t
i
m
e
o
f
d
i
a
g
n
o
s
i
s
.
10
DIAGNOSTIC
STUDIES
4
-
O
R
A
L
C
H
O
L
E
C
Y
S
T
O
G
R
A
P
H
Y
•
O
L
D
D
A
Y
S
:
d
i
a
g
n
o
s
t
i
c
p
r
o
c
e
d
u
r
e
o
f
c
h
o
i
c
e
f
o
r
g
a
l
l
s
t
o
n
e
s
,
•
Replaced by
ultrasonography.
•
oral administration of a radiopaque
compound
•
absorbed, excreted by the
liver,
and passed into the
GB.
•
S
t
o
n
e
s
a
r
e
n
o
t
e
d
o
n
a
f
i
l
m
a
s
F
I
L
L
I
N
G
D
E
F
E
C
T
S
i
n
a
v
i
s
u
a
l
i
z
e
d
,
o
p
a
c
i
f
i
e
d
g
a
l
l
b
l
a
d
d
e
r
.
•
Oral cholecystography is of no value
in:
•
patients
with
intestinal
malabsorption
,
vomiting, obstructive jaundice, and
hepatic
failure.
S
T
O
N
E
F
I
L
L
I
N
G
D
E
F
E
C
T
S
DIAGNOSTIC
STUDIES
5
-
B
I
L
I
A
R
Y
R
A
D
I
O
N
U
C
L
I
D
E
S
C
A
N
N
I
N
G
(
H
I
D
A
S
C
A
N
)
•
noninvasive
evaluation
of the
liver,
gallbladder,
bile
ducts,
and
duodenum with both anatomic and functional
information
•
dimethyl iminodiacetic
acid
(HIDA)
are injected
intravenously,
cleared
by
the
Kupffer
cells in
the
liver,
and
excreted
in
the
bile.
•
U
p
t
a
k
e
b
y
t
h
e
l
i
v
e
r
:
1
0
m
i
n
u
t
e
s
•
G
B
,
b
i
l
e
d
u
c
t
s
&
t
h
e
d
u
o
d
e
n
u
m
:
v
i
s
u
a
l
i
z
e
d
w
i
t
h
i
n
6
0
m
i
n
u
t
e
s
(
f
a
s
t
i
n
g
)
DIAGNOSTIC
STUDIES
•
P
R
I
M
A
R
Y
U
S
E
:
d
i
a
g
n
o
s
i
s
o
f
A
C
U
T
E
C
H
O
L
E
C
Y
S
T
I
T
I
S
•
a
p
p
e
a
r
s
a
s
a
n
o
n
v
i
s
u
a
l
i
z
e
d
g
a
l
l
b
l
a
d
d
e
r
A
F
T
E
R
4
H
O
U
R
S
w
i
t
h
p
r
o
m
p
t
f
i
l
l
i
n
g
o
f
t
h
e
c
o
m
m
o
n
b
i
l
e
d
u
c
t
a
n
d
d
u
o
d
e
n
u
m
•
Biliary leaks
as a complication of surgery can
be
identified.
13
•
Normal
cholescintigrams
normal gallbladder
filling
within 45
minutes.
No filling of the
gallbladder
cystic duct
obstruction.
12/29/201
8
4
5
DIAGNOSTIC
STUDIES
6
-
C
O
M
P
U
T
E
D
T
O
M
O
G
R
A
P
H
Y
•
I
n
f
e
r
i
o
r
t
o
U
T
Z
i
n
d
i
a
g
n
o
s
i
n
g
g
a
l
l
s
t
o
n
e
s
.
•
T
E
S
T
O
F
C
H
O
I
C
E
i
n
e
v
a
l
u
a
t
i
n
g
•
s
u
s
p
e
c
t
e
d
M
A
L
I
G
N
A
N
C
Y
o
f
t
h
e
g
a
l
l
b
l
a
d
d
e
r
,
t
h
e
e
x
t
r
a
h
e
p
a
t
i
c
b
i
l
i
a
r
y
s
y
s
t
e
m
,
h
e
a
d
o
f
t
h
e
p
a
n
c
r
e
a
s
.
•
Spiral CT scanning provides
additional
staging
information,
including vascular
involvement in
patients
with periampullary
tumors
CT scan shows pearl gallstones
and thickening of the gallbladder
wall.
DIAGNOSTIC
STUDIES
7
-
P
E
R
C
U
T
A
N
E
O
U
S
T
R
A
N
S
H
E
P
A
T
I
C
C
H
O
L
A
N
G
I
O
G
R
A
P
H
Y
(
P
T
C
)
•
Intrahepatic
bile
ducts
are
accessed percutaneously
with a small
needle
under fluoroscopic
guidance.
•
Once
the
position
in a bile
duct
has
been confirmed,
a
guidewire is
passed,
and
subsequently,
a
catheter
is
passed
over the
wire
•
Through the
catheter,
a cholangiogram can
be performed
and
therapeutic interventions done, such
as
biliary drain insertions
and
stent
placements.
16
DIAGNOSTIC
STUDIES
P
E
R
C
U
T
A
N
E
O
U
S
T
R
A
N
S
H
E
P
A
T
I
C
C
H
O
L
A
N
G
I
O
G
R
A
P
H
Y
(
P
T
C
)
•
l
i
t
t
l
e
r
o
l
e
i
n
t
h
e
u
n
c
o
m
p
l
i
c
a
t
e
d
g
a
l
l
s
t
o
n
e
d
i
s
e
a
s
e
•
p
a
r
t
i
c
u
l
a
r
l
y
u
s
e
f
u
l
i
n
p
a
t
i
e
n
t
s
w
i
t
h
B
I
L
E
D
U
C
T
S
T
R
I
C
T
U
R
E
S
A
N
D
T
U
M
O
R
S
d
e
f
i
n
e
s
t
h
e
a
n
a
t
o
m
y
o
f
t
h
e
b
i
l
i
a
r
y
t
r
e
e
p
r
o
x
i
m
a
l
t
o
t
h
e
a
f
f
e
c
t
e
d
s
e
g
m
e
n
t
.
•
potential
risks
•
bleeding, cholangitis,
bile
leak
17
DIAGNOSTIC
STUDIES
B
I
L
E
D
U
C
T
S
T
R
I
C
T
U
R
E
S
P
E
R
C
U
T
A
N
E
O
U
S
T
R
A
N
S
H
E
P
A
T
I
C
C
H
O
L
A
N
G
I
O
G
R
A
P
H
Y
(
P
T
C
)
DIAGNOSTIC
STUDIES
8
-
M
A
G
N
E
T
I
C
R
E
S
O
N
A
N
C
E
I
M
A
G
I
N
G
•
M
R
I
p
r
o
v
i
d
e
s
A
N
A
T
O
M
I
C
D
E
T
A
I
L
S
o
f
t
h
e
l
i
v
e
r
,
g
a
l
l
b
l
a
d
d
e
r
,
a
n
d
p
a
n
c
r
e
a
s
s
i
m
i
l
a
r
t
o
t
h
o
s
e
o
b
t
a
i
n
e
d
f
r
o
m
C
T
.
•
can generate high-resolution anatomic
images
•
sensitivity and specificity of 95% and 89%
respectively,
at detecting
choledocholithiasis.
•
M
A
G
N
E
T
I
C
R
E
S
O
N
A
N
C
E
C
H
O
L
A
N
G
I
O
P
A
N
C
R
E
A
T
O
G
R
A
P
H
Y
(
M
R
C
P
)
•
offers
a single noninvasive
test for the
diagnosis
of
biliary
tract
and pancreatic
disease
course of the extrahepatic bile
ducts
(
arrow
)
and
pancreatic duct
(
arrowheads
)
19
DIAGNOSTIC
STUDIES
9
-
E
N
D
O
S
C
O
P
I
C
R
E
T
R
O
G
R
A
D
E
C
H
O
L
A
N
G
I
O
P
A
N
C
R
E
A
T
O
G
R
A
P
H
Y
(
E
R
C
P
)
Using a side-viewing endoscope, the
common bile duct can be cannulated
and
a
cholangiogram
performed using
fluoroscopy
•
requires intravenous (IV)
sedation
for the
patient.
20
ERCP
•
T
h
e
A
D
V
A
N
T
A
G
E
S
O
F
E
R
C
i
n
c
l
u
d
e
•
direct visualization of the ampullary
region
•
direct access to the distal common bile
duct,
with the
possibility
of
therapeutic intervention.
•
ERC
P
is the diagnostic
and often therapeutic
procedure of
choice.
•
Once the endoscopic cholangiogram
has shown
ductal
stones, sphincterotomy
and
stone extraction
can be
performed,
and the common bile duct
cleared of
stones
21
DIAGNOSTIC
STUDIES
•
E
N
D
O
S
C
O
P
I
C
R
E
T
R
O
G
R
A
D
E
C
H
O
L
A
N
G
I
O
P
A
N
C
R
E
A
T
O
G
R
A
P
H
Y
(
E
R
C
P
)
•
S
U
C
C
E
S
S
R
A
T
E
o
f
c
o
m
m
o
n
b
i
l
e
d
u
c
t
c
a
n
n
u
l
a
t
i
o
n
a
n
d
c
h
o
l
a
n
g
i
o
g
r
a
p
h
y
>
9
0
%
.
•
C
O
M
P
L
I
C
A
T
I
O
N
S
o
f
d
i
a
g
n
o
s
t
i
c
E
R
C
•
pancreatitis and cholangitis
(5%)
•
considered
safe
•
T
H
E
R
A
P
E
U
T
I
C
A
P
P
L
I
C
A
T
I
O
N
S
•
biliary stone lithotripsy & extraction in
high-
risk surgical
patients
12/29/201
8
22
E
N
D
O
S
C
O
P
I
C
R
E
T
R
O
G
R
A
D
E
C
H
O
L
A
N
G
I
O
G
R
A
P
H
Y
.
A
.
A
s
c
h
e
m
a
t
i
c
p
i
c
t
u
r
e
s
h
o
w
i
n
g
t
h
e
s
i
d
e
-
v
i
e
w
i
n
g
e
n
d
o
s
c
o
p
e
i
n
t
h
e
D
U
O
D
E
N
U
M
a
n
d
a
c
a
t
h
e
t
e
r
i
n
t
h
e
c
o
m
m
o
n
b
i
l
e
d
u
c
t
.
B
.
A
n
e
n
d
o
s
c
o
p
i
c
c
h
o
l
a
n
g
i
o
g
r
a
p
h
y
s
h
o
w
i
n
g
s
t
o
n
e
s
i
n
t
h
e
C
O
M
M
O
N
B
I
L
E
D
U
C
T
.
T
h
e
c
a
t
h
e
t
e
r
h
a
s
b
e
e
n
p
l
a
c
e
d
i
n
t
h
e
a
m
p
u
l
l
a
o
f
V
a
t
e
r
(
a
r
r
o
w
)
.
N
o
t
e
s
h
a
d
o
w
i
n
d
i
c
a
t
e
d
w
i
t
h
a
r
r
o
w
h
e
a
d
s
.
54
DIAGNOSTIC
STUDIES
1
0
-
E
N
D
O
S
C
O
P
I
C
U
L
T
R
A
S
O
U
N
D
•
special endoscope
with
an
ultrasound
transducer at
its
tip.
•
operator
dependent,
but
offer
noninvasive imaging
of the
bile
ducts
and
adjacent
structures.
•
O
f
p
a
r
t
i
c
u
l
a
r
v
a
l
u
e
i
n
t
h
e
E
V
A
L
U
A
T
I
O
N
O
F
T
U
M
O
R
S
&
t
h
e
i
r
R
E
S
E
C
T
A
B
I
L
I
T
Y
.
•
T
h
e
u
l
t
r
a
s
o
u
n
d
e
n
d
o
s
c
o
p
e
h
a
s
a
B
I
O
P
S
Y
C
H
A
N
N
E
L
•
needle biopsies
of
a
tumor
under ultrasonic
guidance
•
Can identify bile
duct
stones
•
less sensitive than
ERC
•
l
e
s
s
i
n
v
a
s
i
v
e
a
s
c
a
n
n
u
l
a
t
i
o
n
o
f
t
h
e
s
p
h
i
n
c
t
e
r
o
f
O
d
d
i
i
s
n
o
t
n
e
c
e
s
s
a
r
y
f
o
r
55
E
N
D
O
S
C
O
P
I
C
U
L
T
R
A
S
O
U
N
D
56
DIAGNOSTIC
STUDIES
E
N
D
O
S
C
O
P
I
C
U
L
T
R
A
S
O
U
N
D
26
EUS demonstrating a small stone (arrowed) within
the
common bile duct that was not observed on
MRCP
TREATMENT
AND
MANAGEMENT
27
TREATMENT
1
-
C
h
o
l
e
c
y
s
t
o
s
t
o
m
y
2
-
C
h
o
l
e
c
y
s
t
e
c
t
o
m
y
-
L
a
p
a
r
o
s
c
o
p
i
c
C
h
o
l
e
c
y
s
t
e
c
t
o
m
y
-
O
p
e
n
C
h
o
l
e
c
y
s
t
e
c
t
o
m
y
3
-
C
h
o
l
e
d
o
c
h
o
d
u
o
d
e
n
o
s
t
o
m
y
(
L
e
a
s
t
r
e
c
u
r
r
e
n
c
e
)
28
12/29/201
8
TREATMENT
1
-
C
h
o
l
e
c
y
s
t
o
s
t
o
m
y
•
Decompresses and
drains
the
distended
inflamed,
hydropic,
or purulent
gallbladder.
•
applicable if the
patient
is not fit
to tolerate an
abdominal
operation.
•
Ultrasound-guided
percutaneous
drainage with a
pigtail catheter
is the
procedure of
choice.
30
TREATMENT
•
S
y
m
p
t
o
m
a
t
i
c
g
a
l
l
s
t
o
n
e
s
+
s
u
s
p
e
c
t
e
d
c
o
m
m
o
n
b
i
l
e
d
u
c
t
s
t
o
n
e
s
,
e
i
t
h
e
r
:
•
preoperative endoscopic cholangiography
or
•
intraoperative
cholangiogram
•
I
f
a
n
E
N
D
O
S
C
O
P
I
C
C
H
O
L
A
N
G
I
O
G
R
A
M
r
e
v
e
a
l
s
s
t
o
n
e
s
•
sphincterotomy and
ductal
clearance of
the stones is
appropriate,
•
followed by a
laparoscopic
cholecystectomy.
31
TREATMENT
•
A
n
I
N
T
R
A
O
P
E
R
A
T
I
V
E
C
H
O
L
A
N
G
I
O
G
R
A
M
(
I
O
C
)
•
at the time of
cholecystectomy
•
will also document
the
presence or absence
of
bile
duct
stones
•
O
p
e
n
c
o
m
m
o
n
b
i
l
e
d
u
c
t
e
x
p
l
o
r
a
t
i
o
n
•
option
if the
endoscopic method is
not
feasible
•
A
M
P
U
L
L
A
R
Y
S
T
O
N
E
S
C
B
D
>
2
c
m
,
C
B
D
E
/
E
n
d
o
s
c
o
p
y
a
r
e
d
i
f
f
i
c
u
l
t
.
•
choledochoduodenostomy
OR
•
a Roux-en-Y
choledochojejunostomy
32
TREATMENT
•
R
E
T
A
I
N
E
D
S
T
O
N
E
S
•
ERCP
-
confirmed retained CBD
stones, treat
with
ERCP.
•
stones
deliberately left
in
place
at the time of
surgery
•
retrieved either endoscopically or via
the
T-tube
tract
once
it
has
matured
(2–4
weeks
)
•
R
E
C
U
R
R
E
N
T
S
T
O
N
E
S
•
diagnosed months or years
later,
multiple&
large
•
endoscopic sphincterotomy
stone
retrieval
•
Retained or
recurrent
stones following
cholecystectomy
are
best
treated
E
N
D
O
S
C
O
P
I
C
A
L
L
Y
33
OPEN CBD EXPLORATION
The frequency of open exploration has decreased.
This should be used when endoscopic and laparoscopic means are not feasible for
documented CBD stones .
Open cholecystectomy , intra op cholangiogram ,choledocholithotomy whit T-tube
placement.
Burhenne technique=>percutaneous stone extraction via T tube tract after 4-6w using
choledochoscope
COMMON BILE
DUCT DRAINAGE
PROCEDURES
•
Rarely,
when the stones
cannot
be
cleared
and/or
when
the
duct
is
very
dilated (>1.5 cm
in diameter),
a
choledochal
drainage
procedure is
performed
•
Choledochoduodenostomy
is
performed
by mobilizing the
second
part of the duodenum (a Kocher
maneuver) and anastomosing it
side
to side with the common
bile
duct.
36
COMMON BILE
DUCT DRAINAGE
PROCEDURES
•
A
choledochojejunostomy
is done by
bringing up a 45-cm Roux-en-Y limb
of
jejunum and anastomosing
it
end
to
side
to the
common bile
duct.
•
Choledochojejunostomy
or,
more
often,
a
hepaticojejunostomy,
also can be used
to
repair common bile
duct strictures
or as
a palliative procedure
for
malignant
obstruction in
the
periampullary region.
If
the common bile
duct
has been
transected or injured,
it
can be managed
by an
end-to-
end
choledochojejunostomy
37
TRANSDUODENAL
SPHINCTEROTOMY
•
Endoscopic sphincterotomy has
replaced
open
transduodenal
sphincterotomy.
•
Open procedure
- stones
are impacted,
recurrent,
or
multiple,
the
transduodenal approach
may be
feasible.
12/29/201
8
38
COMPLICATION
T
w
o
m
a
i
n
c
o
m
p
l
i
c
a
t
i
o
n
s
o
f
c
h
o
l
e
d
o
c
h
a
l
s
t
o
n
e
s
:
1.
C
h
o
l
a
n
g
i
t
i
s
2.
G
a
l
l
s
t
o
n
e
p
a
n
c
r
e
a
t
i
t
i
s
.
39
Thank you
40
Choledocholithiasis, the presence of stones in the common bile duct, is a common condition found in a percentage of patients with gallstones. The stones can be primary or secondary, causing a range of clinical manifestations from silent obstruction to cholangitis or gallstone pancreatitis. Diagnosis often involves routine blood tests and liver function tests, with bilirubin levels being a significant predictor for CBD stones. Symptoms may include pain, jaundice, and tenderness in the abdomen. Recognizing the signs and symptoms of choledocholithiasis is crucial for prompt management and treatment.
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CHOLEDOCHOLITHIASIS Common bile duct stones Small or large single or multiple Found in 6% to 12% of patients with stones in the GB The incidence increases with age. 2
CHOLEDOCHOLITHIASIS Primary CBD Stones that form in the bile ducts. Usually brown pigment type associated with biliary stasis &infection more commonly seen in Asian populations. The causes of biliary stasis that lead to the development of primary stones include biliary stricture, papillary stenosis, tumors, or other (secondary stones). Secondary CBD stones: formed within the gallbladder migrate down the cystic duct to the common bile duct. usually cholesterol stones 3
CHOLEDOCHOLITHIASIS CLINICAL MANIFESTATIONS SILENT ,often discovered incidentally. may cause obstruction, complete or incomplete,OR may manifest with cholangitis or gallstone pancreatitis. The PAIN of CBD Stone, also biliary colic (similar to cystic duct stone)=>Jaundice , Nausea and vomiting are common. 4
CHOLEDOCHOLITHIASIS PHYSICAL EXAMINATION may be normal, but mild epigastric or RUQ tenderness as well as mild icterus are common. The symptoms intermittent; pain and transient jaundice (temporarily impacts the ampulla but subsequently moves away, acting as a ball valve ) CBD stone resolution pass through the ampulla spontaneously become completely impacted severe progressive jaundice. 5
DIAGNOSTICSTUDIES ROUTINE Blood Tests : 1- CBC Increased WBC : raise suspicion of CHOLECYSTITIS. 2- LIVER FUNCTION TEST elevation of bilirubin, alkaline phosphatase, and aminotransferase, CHOLANGITIS should be suspected. elevation of conjugated bilirubin and a rise in alkaline phosphatase CHOLESTASIS. Serum aminotransferases may be normal or mildly elevated. In patients with biliary colic or chronic cholecystitis blood tests will typically be normal. 6
INITIALINVESTIGATIONS Liver Function Test (LFT) Completely normal: NPV > 97% Abnormal: PPV 15% Bilirubin is the strongest predictor for CBD stones ;specificity varies according to level Bilirubin 30 mol/L: specificity 60% Bilirubin 68 mol/L: specificity 75% Mean bilirubin in CBD stones: 25.5 32.3 mol/L 7
DIAGNOSTICSTUDIES 1-ULTRASONOGRAPHY Advantages: Initial investigation of GBD Noninvasive, painless, No radiation exposure can be performed on critically ill patients. Adjacent organs can frequently be examined at the same time. Disadvantages Operator dependent Not satisfactory for Obese patients, patients with ascites & distended bowel 8
DIAGNOSTICSTUDIES ULTRASONOGRAPHY GALLSTONE sensitivity and specificity >90%) dense, acoustic shadow Move with changes in position POLYPS may be calcified reflect shadows do not move with change in posture. Acoustic shadows from gall stones. 9
DIAGNOSISSTUDIES 2- Magnetic resonance cholangiography (MRC) provides excellent anatomic detail sensitivity and specificity of 95% and 89% detecting choledocholithiasis >5 mm in diameter 3- Endoscopic cholangiography (ERC) GOLD STANDARD FOR DIAGNOSING COMMON BILE DUCT STONES. distinct advantage : THERAPEUTIC OPTION at the time of diagnosis. 10
DIAGNOSTICSTUDIES 4- ORAL CHOLECYSTOGRAPHY OLD DAYS : diagnostic procedure of choice for gallstones, Replaced by ultrasonography. STONE FILLING DEFECTS oral administration of a radiopaquecompound absorbed, excreted by the liver, and passed into theGB. Stones are noted on a film as FILLING DEFECTS in a visualized, opacified gallbladder. Oral cholecystography is of no value in: patients with intestinal malabsorption ,vomiting, obstructive jaundice, and hepatic failure.
DIAGNOSTICSTUDIES 5- BILIARY RADIONUCLIDE SCANNING (HIDA SCAN) noninvasive evaluation of the liver, gallbladder, bile ducts, and duodenum with both anatomic and functional information dimethyl iminodiacetic acid (HIDA) are injected intravenously, cleared by the Kupffer cells in the liver, and excreted in the bile. Uptake by the liver : 10 minutes GB, bile ducts & the duodenum : visualized within 60 minutes (fasting)
DIAGNOSTICSTUDIES PRIMARY USE : diagnosis of ACUTE CHOLECYSTITIS appears as a nonvisualized gallbladder AFTER 4 HOURS with prompt filling of the common bile duct and duodenum Biliary leaks as a complication of surgery can be identified. 13
Normal cholescintigrams normal gallbladder filling within 45 minutes. 12/29/2018 4 No filling of the gallbladder cystic duct obstruction. 5
DIAGNOSTICSTUDIES 6- COMPUTED TOMOGRAPHY Inferior to UTZ in diagnosing gallstones. TEST OF CHOICE in evaluating suspected MALIGNANCY of the gallbladder, the extrahepatic biliary system, head of the pancreas. CT scan shows pearl gallstones and thickening of the gallbladder wall. Spiral CT scanning provides additional staging information, including vascular involvement in patients with periampullary tumors
DIAGNOSTICSTUDIES 7- PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY (PTC) Intrahepatic bile ducts are accessed percutaneously with a small needle under fluoroscopic guidance. Once the position in a bile duct has been confirmed, a guidewire is passed, and subsequently, a catheter is passed over the wire Through the catheter, a cholangiogram can be performed and therapeutic interventions done, such as biliary drain insertions and stent placements. 16
DIAGNOSTICSTUDIES PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY (PTC) little role in the uncomplicated gallstone disease particularly useful in patients with BILE DUCT STRICTURES AND TUMORS defines the anatomy of the biliary tree proximal to the affected segment. potential risks bleeding, cholangitis, bile leak 17
DIAGNOSTICSTUDIES PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY (PTC) BILE DUCT STRICTURES
DIAGNOSTICSTUDIES 8- MAGNETIC RESONANCE IMAGING MRI provides ANATOMIC DETAILS of the liver, gallbladder, and pancreas similar to those obtained from CT. can generate high-resolution anatomicimages sensitivity and specificity of 95% and 89% respectively, at detecting choledocholithiasis. MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY (MRCP) offers a single noninvasive test for the diagnosis of biliary tract and pancreatic disease course of the extrahepatic bile ducts (arrow) and pancreatic duct (arrowheads) 19
DIAGNOSTICSTUDIES 9- ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP) Using a side-viewing endoscope, the common bile duct can be cannulated and a cholangiogram performed using fluoroscopy requires intravenous (IV) sedation for the patient. 20
ERCP The ADVANTAGES OF ERC include direct visualization of the ampullary region direct access to the distal common bile duct, with the possibility of therapeutic intervention. ERCP is the diagnostic and often therapeutic procedure of choice. Once the endoscopic cholangiogram has shown ductal stones, sphincterotomy and stone extraction can be performed, and the common bile duct cleared of stones 21
DIAGNOSTICSTUDIES ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP) SUCCESS RATE of common bile duct cannulation and cholangiography >90%. COMPLICATIONS of diagnostic ERC pancreatitis and cholangitis (5%) considered safe THERAPEUTIC APPLICATIONS biliary stone lithotripsy & extraction in high- risk surgical patients 12/29/201 8 22
ENDOSCOPIC RETROGRADE CHOLANGIOGRAPHY. B. An endoscopic cholangiography showing stones in the COMMON BILE DUCT. The catheter has been placed in the ampulla of Vater (arrow). Note shadow indicated with arrowheads. A. A schematic picture showing the side-viewing endoscope in the DUODENUM and a catheter in the common bile duct. 54
DIAGNOSTICSTUDIES 10- ENDOSCOPIC ULTRASOUND special endoscope with an ultrasound transducer at its tip. operator dependent, but offer noninvasive imaging of the bile ducts and adjacent structures. Of particular value in the EVALUATION OF TUMORS & their RESECTABILITY. The ultrasound endoscope has a BIOPSY CHANNEL needle biopsies of a tumor under ultrasonic guidance Can identify bile duct stones less sensitive than ERC less invasive as cannulation of the sphincter of Oddi is not necessary for 55
56 ENDOSCOPIC ULTRASOUND
DIAGNOSTICSTUDIES EUS demonstrating a small stone (arrowed) within the common bile duct that was not observed on MRCP ENDOSCOPIC ULTRASOUND 26
TREATMENT AND MANAGEMENT 27
TREATMENT 1- Cholecystostomy 2- Cholecystectomy - Laparoscopic Cholecystectomy - Open Cholecystectomy 3- Choledochoduodenostomy (Least recurrence) 28
TREATMENT 1- Cholecystostomy Decompresses and drains the distended inflamed, hydropic, or purulent gallbladder. applicable if the patient is not fit to tolerate an abdominal operation. Ultrasound-guided percutaneous drainage with a pigtail catheter procedure of choice. is the 30
TREATMENT Symptomatic gallstones+ suspected common bile duct stones, either: preoperative endoscopic cholangiography or intraoperative cholangiogram If an ENDOSCOPIC CHOLANGIOGRAM reveals stones sphincterotomy and ductal clearance of the stones is appropriate, followed by a laparoscopic cholecystectomy. 31
TREATMENT An INTRAOPERATIVE CHOLANGIOGRAM (IOC) at the time of cholecystectomy will also document the presence or absence of bile duct stones Open common bile duct exploration option if the endoscopic method is not feasible AMPULLARY STONES CBD >2cm, CBDE/Endoscopy are difficult. choledochoduodenostomy OR a Roux-en-Y choledochojejunostomy 32
TREATMENT RETAINED STONES ERCP- confirmed retained CBD stones, treat with ERCP. stones deliberately left in place at the time of surgery retrieved either endoscopically or via the T-tube tract once it has matured (2 4 weeks) RECURRENT STONES diagnosed months or years later, multiple& large endoscopic sphincterotomy stone retrieval Retained or recurrent stones following cholecystectomy are best treated ENDOSCOPICALLY 33
OPEN CBD EXPLORATION The frequency of open exploration has decreased. This should be used when endoscopic and laparoscopic means are not feasible for documented CBD stones . Open cholecystectomy , intra op cholangiogram ,choledocholithotomy whit T-tube placement. Burhenne technique=>percutaneous stone extraction via T tube tract after 4-6w using choledochoscope
COMMON BILE DUCT DRAINAGE PROCEDURES Rarely, when the stones cannot be cleared and/or when the duct is very dilated (>1.5 cm in diameter), a choledochal drainage procedure is performed Choledochoduodenostomy is performed by mobilizing the second part of the duodenum (a Kocher maneuver) and anastomosing it side to side with the common bile duct. 36
COMMON BILE DUCT DRAINAGE PROCEDURES A choledochojejunostomy is done by bringing up a 45-cm Roux-en-Y limb of jejunum and anastomosing it end to side to the common bile duct. Choledochojejunostomy or, more often, a hepaticojejunostomy, also can be used to repair common bile duct strictures or as a palliative procedure for malignant obstruction in the periampullary region. If the common bile duct has been transected or injured, it can be managed by an end-to- end choledochojejunostomy 37
TRANSDUODENAL SPHINCTEROTOMY Endoscopic sphincterotomy has replaced open transduodenal sphincterotomy. Open procedure - stones are impacted, recurrent, or multiple, the transduodenal approach may be feasible. 12/29/201 8 38
COMPLICATION Two main complications of choledochal stones: 1. Cholangitis 2. Gallstone pancreatitis. 39
Thank you 40
