CHOLEDOCHOLITHIASIS

CHOLEDOCHOLITHIASISGROUP CSalazar, RiccelSalcedo, VonSaldana, EmmanuelSales, Maria StephanieSalonga, Cryscel

September 21, 2009

Pathophysiology

Choledocholithiasis occurs as a result of either the primary formation of stones in the common bile duct (CBD) or the passage of gallstones from the gallbladder through the cystic duct into the CBD.

http://www.nlm.nih.gov/medlineplus/ency/article/000274.htm

Pathophysiology

Majority of the bile duct stones are cholesterol stones formed in the gallbladder which then migrates into the exrahepatic biliary tree through the cystic duct [secondary ]

Obstruction of the CBD by gallstones leads to symptoms and complications that include pain, jaundice, cholangitis, pancreatits and sepsis.

Harrison’s Principles of Internal Medicine 17th ed p.1999

Causes of Primary calculi in CBD 1. Hepatobiliary parasitism or

chronic, recurrent cholangitis 2. Congenital anomalies of the bile

ducts 3. Dilated or sclerosed or strictured

ducts 4. MD3 gene defect leading to

impaired biliary phospholipids secretion

Harrison’s Principles of Internal Medicine 17th ed p.1999

Causes of Secondary stones 1. Cholesterol stones 2. Black pigment stones 3. Brown pigment stones

Secondary stones are those who were formed in the gallbladder and later on migrate into the CBD

Risk Factors for developing choledocholelithiasis

Age

• 25% of elderly patients may have calculi in the CBD

Previous History of Gallstones

• Undetected duct stones are left behind in ~1-5% of cholecystectomy patients

Infection with parasites

• Ascaris Lumbricoides

• Clonorchis sinensis


Clinical Manifestations Can be completely asymptomatic Symptoms usually do not occur

unless the stone blocks the common bile duct

Symptoms and signs usually present as RUQ abdominal pain Jaundice Fever Tea colored urine Acholic stools Nausea and or Vomiting

Abdominal PainPresentation

• Pain in RUQ or MUQ

• Sharp, cramping or dull

• Pain radiating to the back or below the scapula

• Pain worsening after eating fatty/greasy food

Patient• In our Patient:• - Denies of

having abdominal pain

• [But choledocholelithiasis can present as a painless jaundice]

Jaundice Presentation

• Painless jaundice may occur in patients with cholelithiasis

• -caused by increased bilirubin in the blood

• - post hepatic/obstructive jaundice

• Initially presents as Icteric sclera

Patient• Positive for

jaundice

Tea-colored urine and Acholic Stools

Presentation• signifies post hepatic cause of jaundice [Obstructive Jaundice]

Patient• Positive for Tea/Dark Colored urine

• Patient denies acholic stools

COMPLICATIONS

Cholangitis

May be acute or chronic Symptoms result from inflammation

Caused by partial obstruction to the flow of bile

Presence of bacteria in the bile culture in 75% of patients with acute cholangitis early in the symptomatic course

Cholangitis

CHARCOT’S TRIAD Characteristic presentation of acute cholangitis Biliary pain, jaundice and spiking fever

with chills Blood cultures are frequently positive, and

leukocytosis is typicalNonsuppurative acute cholangitis

Most common and may respond relatively rapidly to supportive measures and to treatment with antibiotics

Cholangitis

Suppurative acute cholangitis Presence of pus under pressure in a

completely obstructed ductal system leads to symptoms of toxicity▪ REYNOLDS PENTAD▪ Mental confusion and septic shock▪ Biliary pain, jaundice and spiking fever with

chills Response to antibiotics is poor Multiple hepatic abscesses are present Mortality rate approaches 100% ▪ Endoscopic or surgical relief of the

obstruction and drainage of the infected bile

Cholangitis

Endoscopic management Effective as surgical intervention

ERCP with endoscopic sphincterotomy Preferred initial procedure for both

establishing a definitive diagnosis and providing effective therapy

Safe

Obstructive Jaundice

Gradual obstruction of the CBD jaundice or pruritus without associated symptoms of biliary colic or cholangitis

Painless jaundice Associated chronic calculous

cholecystitis is very common Absence of a palpable gallbladder

Biliary obstruction causes progressive dilatation of the intrahepatic bile ducts

Hepatic bile flow is suppressed

Reabsorption and regurgitation of conjugated bilirubin into the bloodstream

Jaundice, dark urine (bilirubinuria), light-colored (acholic) stools

Obstructive Jaundice CBD stones should be suspected in any

patient with cholecystitis whose serum bilirubin level is >85.5 mol/L (5 mg/dL)

Maximum bilirubin level is seldom >256.5 mol/L (15.0 mg/dL) in patients with choledocholithiasis

Serum alkaline phosphatase level is almost always elevated

May be a two- to tenfold elevation of serum aminotransferases, especially in association with acute obstruction

Pancreatitis

Most common associated entity discovered in patients with nonalcoholic acute pancreatitis is biliary tract disease

Complicates: acute cholecystitis: 15% Choledocholithiasis: >30%

Common factor appears to be the passage of gallstones through the common duct

Pancreatitis

Coexisting pancreatitis should be suspected in patients with symptoms of cholecystitis who develop: back pain or pain to the left of the abdominal

midline prolonged vomiting with paralytic ileus a pleural effusion, especially on the left side

Surgical treatment of gallstone disease is usually associated with resolution of the pancreatitis

Secondary Biliary Cirrhosis May complicate prolonged or intermittent

duct obstruction with or without recurrent cholangitis

May be progressive even after correction of the obstructing process

Increasingly severe hepatic cirrhosis may lead to portal hypertension or to hepatic failure and death

May also be associated with clinically relevant deficiencies of the fat-soluble vitamins A, D, E, and K

DIAGNOSIS

DIAGNOSIS Laboratory studies Imaging studies

Ultrasonography MRC Endoscopic cholangiography

Laboratory Studies

Not specific for the diagnosis of choledocholithiasis

Increase in serum bilirubin, alkaline phosphatase, gamma-glutamyl transpeptidase

Moderate elevations on aminotranferases

Ultrasonography

•Commonly the first test•Useful for documenting stones in the gallbladder and determining the size of the common bile duct (90% accuracy). Shows a dilated common bile duct (>8 mm in diameter) in a patient with gallstones, jaundice, and biliary pain - highly suggestive of common bile duct stones. •Detection of CBD stones is impeded by the presence of gas in the duodenum, possible reflection and refraction of the sound beam by curvature of the duct, and the location of the duct beyond the optimal focal point of the transducer

Very accurate in the detection of biliary tree obstruction and ductal dilatation, both intrahepatic and extrahepatic.

Has a sensitivity of 75-90% in the detection of CBD stones, which makes it an essential tool in the evaluation of patients with jaundice.

Capable of defining the level of the obstruction and provides information about the surrounding structures, especially the pancreas.

MAGNETIC RESONANCE CHOLANGIOGRAPHY

Provides excellent anatomic detail and has a sensitivity and specificity of 95 and 89%, respectively, at detecting choledocholithiasis

Cost, inconvenience, and limitations (eg, obesity, presence of metal objects, eg, pacemakers) are some of its disadvantages.

Ultrasonography

Endoscopic cholangiography Gold standard for diagnosing common bile

duct stones Has a distinct advantage of providing a

therapeutic option at the time of diagnosis The CBD is cannulated through the

ampulla, contrast material is injected, and films are obtained. The experience of the endoscopist is the best predictor of success, which is 90-95% in expert hands.

Endoscopic Cholangiogra

phy

ERC from the same patient shows multiple stones in the common bile duct. Only the top one showed on ultrasound, as the other stones lie in the distal common bile duct behind the duodenum.

TREATMENT

Treatment Medical

ERCP Percutaneous extraction Extracorporeal shock wave lithotripsy

Surgical Open choledochotomy Transcystic exploration Drainage procedures ▪ Transduodenal sphincteroplasty ▪ Choledochoduodenostomy▪ Choledochojejunostomy

Cholecystectomy

Treatment Patients with symptomatic gallstones and suspected

common bile duct stones, either preoperative endoscopic cholangiography or an intraoperative cholangiogram will document the bile duct stones.

If an endoscopic cholangiogram reveals stones, sphincterotomy and ductal clearance of the stones is appropriate, followed by a laparoscopic cholecystectomy.

An intraoperative cholangiogram at the time of cholecystectomy will also document the presence or absence of bile duct stones

Laparoscopic common bile duct exploration via the cystic duct or with formal choledochotomy allows the stones to be retrieved in the same setting.

Treatment An open common bile duct exploration is an option

if the endoscopic method has already been tried or is for some reason not feasible.

If a choledochotomy is performed, a T tube is left in place. Stones impacted in the ampulla may be difficult for both endoscopic ductal clearance as well as common bile duct exploration (open or laparoscopic). In these cases the common bile duct is usually

quite dilated (about 2 cm in diameter). Choledochoduodenostomy Roux-en-Y choledochojejunostomy

References

Harrison’s Principles of Internal Medicine, 17th ed.


Documents

CHOLEDOCHOLITHIASIS