“ 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.
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“More Than You Bargained For”
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.
PTC: Right needle access to biliary ducts - fluoroscopy
Over the wire Fogarty Balloon 5 Fr
“ Burhenne” - push
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
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.