“ More Than You Bargained For ”. Dr Asif Khan. Case 1. 38 y/o female. Rt upper quadrant pain and vomiting, deranged LFT’s (obstructive picture) PMH includes ERCP Two stones 8 and 10mm identified but unable to remove, stent was placed and sphincterotomy performed.
Dr Asif Khan
38 y/o female.
Rt upper quadrant pain and vomiting, deranged LFT’s (obstructive picture) PMH includes
Two stones 8 and 10mm identified but unable to remove, stent was placed and sphincterotomy performed.
Afebrile, hemodynamically stable.
Abdomen soft, mildly tender , negative Murphy’s sign.
No rebound tenderness/guarding, no masses appreciated.
WBC 4.6 x 109/L (4-10 109/L )
AST 258 IU/L (14-54 ) ; ALT 352 IU/L (14-54)
Billirubin 77 umol/L (3.4-20.5)
Alkaline phosphatase 258 IU/L ( 42-121)
U/S – Dilated CBD (14mm) containing two stones, one 13 mm.
Blocked stent , dilated CBD , two large stones >1cm in size, small stones and sludge. Stent changed and surgical intervention suggested as stones unretrievable via ERCP
MRCP – planning – pre IR
Confirms ductal stones and dilated ducts
Prominent ducts especially those beyond the stones in the right radicular duct system.
Modified Burhenne PTC technique - feasible
MRCP; to assess interventional approach
Right PTC: Access ducts beyond incarcerated stone -a pre-requisite
PTC and cannulation guide wire technique
Modified “ Burhenne” technique
Over the wire Fogarty Balloon - push
Stones were pushed into the duodenum and stent inserted. CBD was cleared.
Post interventional radiology,
Patient made good recovery
Discharged home no further episodes.
72 y/o female.
Admitted with RUQ pain , fever and jaundice.
Clinical picture of Cholangitis treated with IV antibiotics ,fluid resuscitation and analgesia.
Recurrent admission for symptomatic choledocholithiasis and repeated ERCP attempts
ERCP 1 -failed
ERCP 2 -failed
ERCP 3 -failed
US Abdomen –Multiple gall stones and CBD diameter 1.1 cm.
MRCP - Gall stones and multiple ductal stones , dilated CBD.
ERCP - Unable to remove stones and stent was inserted.
Open cholecystectomy and CBD Exploration
Findings: More than 12 big and small stones removed from CBD. Normal anatomy.
Duct clear on choledochoscopy.
T tube cholangiogram Day 7 post op
Findings: Two retained stones in Rt duct system.
Overnight external drain
Check cholangiogram following morning.
Findings: Duct clear. External drain removal
Gastroenterology Research and Practice Volume 2009, Article ID 840208, 12 pages
Open cholecystectomy + CBD exploration.
ERCP + Endoscopic Sphincterotomy (followed by cholecystectomy – most frequently used).
Laparoscopic cholecystectomy + Laparoscopic CBD exploration – in specialized centers.
Choledochoscopy at laparoscopy or percutaneous choleydochoscopy or choleydochoscopy through T tube.
(Fletcher 1994 ;Cuschieri 1996; Lezoche 1996)
Lella F, Bagnolo F, Colombo E, Bonassi U. A simple way of avoiding post- ERCP pancreatitis. Gastrointest Endosc 2004; 59: 830-834.
Bailey AA, Bourke MJ, Williams SJ, et al. A prospective randomized trial of cannulation technique in ERCP: Effects on technical success and post-ERCP pancreatitis. Endoscopy 2008; 40: 296-301.
British Journal of SurgeryVolume 78 Issue 8, Pages 959 - 960
Vanderburgh L, Yeung EY, Ho CS. Radiologic management of problematic biliary calculi. Sem Intervent Radiol1986; 13:69 –77
Burhenne HJ. Percutaneous extraction of retained biliary tract stones: 661 patients. AJR1980
Lazaraki G, Katsinelos P. Prevention of post- ERCP pancreatitis: an overview. Ann Gastroenterol 2008; 21: 27-38.
Laparoscopic CBD exploration/Choleydochoscopy.
Chemical contact dissolution therapy
techniques have revolutionized management.