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A CASE PRESENTATION, MANAGEMENT, DISCUSSION AND SHARING OF INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS. BY: Jonathan R. Malabanan, M.D. Ospital ng Maynila Medical Center Department of Surgery. General Data: A.M. 35 –years- old Female Binondo, Manila.

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A CASE PRESENTATION, MANAGEMENT, DISCUSSION AND SHARING OF INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

BY:

Jonathan R. Malabanan, M.D.

Ospital ng Maynila Medical Center

Department of Surgery


General Data: INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

A.M.

35 –years- old

Female

Binondo, Manila


Chief Complaint: INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

Yellowish discoloration of the eyes


History of present illness
HISTORY OF PRESENT ILLNESS INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

One month PTC=

=RUQ pain, colicky, moderate to severe, radiating to R scapular area

=no fever, no yellowish discoloration of skin and sclerae

=no consult, no meds


History of present illness1
HISTORY OF PRESENT ILLNESS INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

One week PTC =persistence of colicky right upper quadrant pain

=yellowish discoloration of skin and sclerae

=(+) light colored stool

=(+) consult, HBT- UTZ done: Choledocholithiasis, Cholecystolithiais

Advised OR, and was scheduled for operation


Past medical history
Past Medical History INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

  • No hypertension

  • No diabetes

  • No PTB

  • No previous hospitalization

  • No allergies to foods and drugs


Family history
Family History INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

  • unremarkable


Personal and social history
Personal and Social History INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

  • Unremarkable

  • Occasional alcoholic beverage drinker


Physical examination
Physical Examination INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

  • General Survey:

    • Conscious, coherent, not in respiratory distress

  • Vital Signs

    BP = 110/ 60 mmHg CR = 81 bpm

    RR = 20 cpm Temp: 37 degrees Celsius


Physical examination1
Physical Examination INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

  • Skin: yellowish coloration of skin

  • HEENT:

    -Pink palpebral conjuctivae, icteric sclerae, no CLAD, no TPC, no NAD, supple neck.

  • Chest:

    • Symmetrical chest expansion, no retractions,

    • CBS


Physical examination2
Physical Examination INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

  • Heart

    normal rate, regular rhythm, no murmur

  • Abdomen

    Flat, NABS, soft, with Direct Tenderness RUQ, no organomegaly.


Physical examination3
Physical Examination INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

  • Extremities:

    • Full and equal pulses, no deformities, no cyanosis

      DRE:

      -light colored stool


Salient features
Salient Features INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

  • 1.35/Female

  • 2. RUQ pain

  • 3. Yellowish discoloration of the eyes, skin

  • 4. Light colored stool

  • 5. UTZ result of Hepatobiliary Tree: dilated CBD, normal liver, portal vein and tributaries are unremarkable, intrahepatic ducts not dilated, with an intraluminal echogenic focus exibiting acoustic shadowing


NON OBSTRUCTIVE INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

OBSTRUCTIVE

JAUNDICE

INTRAHEPATIC

EXTRAHEPATIC

INTRADUCTAL

COMPRESSION OF BILIARY TRACTS

HEMOLYSIS

HEPATOCELLULAR


OBSTRUCTIVE INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

EXTRAHEPATIC

INTRAHEPATIC

GB/CBD stones

Pancreatic Ca

Primary Biliary Cirrhosis

Sclerosing Cholangitis

Pattern Recognition (90-95%)

RUQ pain

Clinical Jaundice

CBD dilatation


Initial impression
Initial Impression INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS


Para clinical diagnostic procedure
Para clinical Diagnostic Procedure INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

  • Do I need to perform a Para clinical diagnostic procedure?

    “No”


Pretreatment diagosis
Pretreatment Diagosis INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS


Pre treatment diagnosis
Pre Treatment Diagnosis INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

Obstructive Jaundice prob secondary to

Choledocholithiasis

Cholecystolithiasis


Goals of treatment
GOALS OF TREATMENT INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

  • Resolution of obstruction

  • Prevention of complication


Treatment options
Treatment Options INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

Meta-analysis ofendoscopy and surgery versus surgery alone

for common bile duct stones with the gallbladder in situ, Clayton et.al. University of Athens 2006


Management
Management INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

  • OPEN CBDE

  • CHOLECYSTECTOMY, IOC


Preoperative preparation
Preoperative Preparation INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

  • Informed consent

  • Provide psychosocial support

  • Optimize patient’s condition

  • NPO for 6 hours

  • Preparation of OR materials


Operative technique
Operative technique INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

  • Patient supine under GA

  • Asepsis/Anti-sepsis

  • Sterile drapes placed

  • Right paramedian incision carried down from skin to subcutaneous tissue, fascia and peritoneum entered

  • Intraoperative findings noted


Operative technique1
Operative Technique INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

  • Cystic artery identified, ligated and cut

  • Cystic duct identified, isolated and tagged

  • Gallbladder removed. Intraoperative findings noted.

  • French 5 feeding tube inserted into the cystic duct, IOC done, results noted

  • CBD opened logitudinally and explored


Operative technique2
Operative Technique INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

  • T-tube inserted and anchored

  • Hemostasis

  • Correct sponge and instruments count

  • Layer by layer closure

  • DSD


Operative findings
Operative Findings INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

  • Intraoperative findings noted

    • GB is distended with thickened walls measuring 10x4cm; on opening up, it contained multiple stone measuring 0.2-0.3cm, cystic duct measures 0.5cm in diameter; CBD measured 12mm in diameter; on IOC, there was a filling defect on the distal CBD, there was visualization of both intrahepatic ducts. On CBDE, 8mm primary stone was noted at the distal common bile duct. Pancreas was normal. Liver was noted to be cirrhotic.


Postoperative diagnosis

Postoperative Diagnosis INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

Obstructive Jaundice Secondary to Choledocholithiasis

Cholelithiasis

Operation Done

Open Cholecystectomy, Common Bile Duct Exploration, Intraoperative Cholangiography, T-Tube Choledochostomy


Postoperative management
Postoperative Management INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

  • Adequate analgesia

  • Monitoring of VS and hydration.

  • DAT

  • Adequate monitoring: complications

  • Patient was discharged on the 5th post operative day

  • Follow up after a week.


Final diagnosis
Final Diagnosis INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

  • Obstructive Jaundice Secondary to Choledocholithiasis

  • Cholelithiasis

  • S/P Open Cholecystectomy, Common Bile Duct Exploration, Intraoperative Cholangiography, T-Tube Choledochostomy


Course in the ward
COURSE IN THE WARD INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

  • 1st Hospital Day

    • NPO

    • Adequate Antibiotic

    • Adequate Analgesia

    • DWC


Course in the ward1
COURSE IN THE WARD INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

  • 2nd-3rd Hospital Day

    • GL- Soft diet

    • Adequate Antibiotic

    • Adequate Analgesia

    • DWC


Course in the ward2
COURSE IN THE WARD INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

  • 4th Hospital Day

    • DAT

    • Adequate Antibiotic

    • Adequate Analgesia

    • DWC


Course in the ward3
COURSE IN THE WARD INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

  • 5th Hospital Day

    • Patient discharged


Prevention and health promotion
PREVENTION AND HEALTH PROMOTION INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

  • Advise given to patient regarding

    • Possible complications

    • Proper wound care

  • OPD follow up after 7 days for removal of sutures

  • Anticipate complications

    • Avoid Recurrence

    • Avoid infection


Sharing of informati0n
SHARING OF INFORMATI0N INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS


Common bile duct stones
Common Bile Duct Stones INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

  • 10% of patients who present for Cholecystectomy

  • definitive treatment is cholecystectomy and ductal clearance either through open CBDE, Lap CBDE, ERCP.

  • Manuevers include administration of glucagon and flushing of ductal system,dilatation of the distal CBD, balloon catheter, basket extraction.


Overview to patient management
Overview to Patient Management INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

  • CBD stones can be discovered preoperatively, intraop, post-op.

  • Treatment options:

    • ERCP=/-S

    • Lap CBDE

    • Lap Chole + ERCP

    • Open CBDE

    • almost same success rate


Completion cbde
Completion CBDE INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

  • T tube placement:

    • decompression of the duct, incase of residual obstruction

    • access for ductal imaging postop

    • access for removal of stone

    • left as early as 4 days up to 6 weeks

    • complicatios: bile leaks, peritonitis


Post Cholecystectomy CBDE Problems INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

  • Early Problems

    • bile duct injury: laceration, cystic duct stump leak, liver bed leak

    • bile duct obstruction: retained stone

    • biliary pancreatitis

  • Late Problems

    • stricture

    • postcholecystectomy syndrome

    • GERD


Questions
Questions INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

#1 (MCQ) Which of the following is the main chemical component of pigment stones? A. CholesterolB. Calcium bilirubinate C. Calcium carbonateD. Calcium phosphate

E: Calcium oxalate


Questions1
Questions INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

#2 (MCQ) What is the most commonly isolated bacteria in the common duct of patient with primary stone?

A. Escherichia coli

B. Pseudomonas aeruginosa

C. Klebsiella sp.

D. Salmonella typhii

E. Corynebacterium sp.


Questions2
Questions INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

#3 (MCQ) Which of the following is the best indication for preoperative ERCP in patients with gallstones?

A. Gallstone pancreatitis

B. Obstructive jaundice

C. History of jaundice

D. Increased alkaline phosphatase to twice normal

E. 1.6 cm common bile duct dilatation


Questions3
Questions INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

(MCR)

Direction: Write

“A” if 1, 2, and 3 are valid statements.

“B” if only 1 and 3 are valid statements.

“C” if only 2 and 4 are valid statements.

“D” if only 4 is a valid statement.

“E” if all are valid statements.


Questions4
Questions INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

#4 (MCR)

The following are drainage procedure after open/laparoscopic CBDE.

1. Sphincteroplasty

2. Choledochojeunostomy

3. Choledochoduodenostomy

4. Choledochotomy


Questions5
Questions INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

#5 (MCR)

Correct statement about biliary scintigraphy using technetium 99m- labeled derivatives of iminoacetic acid (HIDA) include:


Questions6
Questions INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

#5 (MCR)

1. Nonvisualization of GB is strong evidence of cystic duct obstruction.

2. The isotope is cleared by Kupffer’s cells

3. The GB in a fasting subject is normally visualized within 60 minutes of the dye injection

4. The scan is the preferred initial step in identifying common duct stones


Journal appraisal
Journal Appraisal INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

  • Evaluation of primary duct closure vs T-tube drainage following choledochotomy

    Marwah Sanjay, Singh Ishwar, Godara Rajesh, Sen Jyotsana, Marwah Nisha, Karwasra RKDepartments of Surgery, Postgraduate Institute of Medical Sciences, Rohtak, Haryana, IndiaYear : 2004  |  Volume : 23  |  Issue : 6  |  Page : 227-228


Objective
Objective INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

  • To assess the benefits and harms of primary closure versus routine T-tube drainage in open common bile duct exploration for common bile duct stones.


Design
Design: INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

  • Randomized Control Trial


Patients
Patients: INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

  • Forty consecutive patients undergoing elective minilap cholecystectomy and CBD exploration for gallstones with CBD stones (proved preoperatively on ultrasonography) were studied prospectively.


Intervention
Intervention: INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

  • Patients were randomly divided in two groups: Group A underwent primary closure of CBD, group B had T-tube drainage after CBD exploration.


Main outcome measures
Main outcome measures: INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

  • The duration of hospital stay, mortalities, morbidities and outcome.


Results
Results: INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS


Results1
Results: INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS


Results2
Results: INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS


Results3
Results: INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS


Results4
Results: INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS


Results5
Results: INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS


Conclusion
Conclusion INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

  • The use of T-tube following routine choledochotomy is unnecessary and increases postoperative morbidity and mortality.


Clinical question
Clinical Question INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

  • In cases of obstructive jaundice secondary to choledocholithiasis, is mandatory t- tube choledochostomy necessary?


Tentative answer
Tentative Answer INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

  • No

    • mandatory t tube choledochosyomy is not necessary for cases of obstructive jaundice secondary to choledocholithiasis.


Appraisal Guide INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS


Are the results of the study valid
Are the results of the study valid? INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

Primary Guides:

1. Was the assignment of patients to treatment randomized?

Yes.


Are the results of the study valid1
Are the results of the study valid? INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

Primary Guides:

2. Were all patients who entered the trial properly accounted for and attributed at its conclusion?

Yes.


Are the results of the study valid2
Are the results of the study valid? INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

Secondary Guides:

Were patients, their clinicians, and study personnel "blind" to treatment?

No.


Are the results of the study valid3
Are the results of the study valid? INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

Secondary Guides:

5. Aside from the experimental intervention, were the groups treated equally?

Yes.


Are the results of the study valid4
Are the results of the study valid? INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

Secondary Guides:

4. Were the groups similar at the start of the trial?

Yes.


Are the results of the study valid5
Are the results of the study valid? INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

Secondary Guides:

4. Were the groups similar at the start of the trial?

Yes.


Conclusion1
Conclusion INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

  • The use of T-tube following routine choledochotomy is unnecessary and increases postoperative morbidity and mortality.

  • Primary closure of CBD is more safe and physiological and the procedure of choice following routine choledochotomy.


References
References INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

  • Schwartz et. al Principles of Surgery.8th ed. Chapter 6.

  • Marwah S, Singh I,Godara R, Sen J,MarwahN, Karwasra RK. Evaluation of primary duct closure vs T-tube drainage following choledochotomy.

    Indian Journal of Gastroenterology 2004;23(6):227–8.

  • Wright BE, Freeman ML, Cummings JK et. al.: Current Management of Common Bile Duct Stones. Surgery. 132:729-735, 2002.


EVIDENCE-BASED CLINICAL PRACTICE GUIDELINES ON COMMON BILE DUCT STONES FOR SURGICAL PROCEDURES:

UPDATE 2004


Common bile duct stones1
COMMON BILE DUCT STONES DUCT STONES FOR SURGICAL PROCEDURES:

  • 1. What is the recommended ancillary procedure in a patient with suspected

    common duct stone to confirm its diagnosis?


Magnetic resonance cholangiography is the recommended procedure for patients with suspected common bile duct stones to confirm the diagnosis.




  • 4. What is the recommended treatment for patients with gall bladder stones after

    endoscopic common bile duct clearance?

  • The recommended treatment for patients with gall bladder stones after endoscopic

    common bile duct clearance is surgery, to be performed within 24 to 48 hours after

    clearance.


Intrahepatic stones hepatolithiasis
INTRAHEPATIC STONES (HEPATOLITHIASIS) bladder stones after

  • 1. What is the recommended diagnostic tool to confirm the presence of intrahepatic

    stones with or without strictures?



  • 2. What is the recommended treatment for intrahepatic stones with or without

    strictures?

  • The recommended treatment include surgical management (hepatic resection) and cholangioscopic techniques, whether through a T-tube tract, a percutaneous transhepatic approach (PTBD/PTCS) or a transpapillary approach, singly or in combination.


Cholangitis
CHOLANGITIS with or without

  • 1. What is the antibiotic of choice for patients with cholangitis?

  • The recommended antibiotics for the treatment of cholangitis are: Ciprofloxacin 200mgs IV BID or Ceftazidime 1gm IV BID + Ampicillin 500mgs IV QID + Metronidazole 500mgs IV TID



Retained common bile duct stones
RETAINED COMMON BILE DUCT STONES severe cholangitis?

  • 1. What is the recommended treatment for retained common bile duct stones?

  • For patients who have had prior cholecystectomy and have a high probability of common bile duct stones, ERCP and sphincterotomy with DORMIA basket extraction is the preferred initial approach.


Thank you! severe cholangitis?


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