Choledocholithiasis - PowerPoint PPT Presentation

Choledocholithiasis

Pathophysiology

Complications

Diagnosis

Treatment

Primary formation of stones in the CBD

*Primary calculi arising de novo in the ducts are usually pigment stones developing in patients with:

(1) hepatobiliary parasitism or chronic, recurrent cholangitis

(2) congenital anomalies of the bile ducts

(3) dilated, sclerosed, or strictured ducts

(4) an MDR3 gene defect leading to impaired biliary phospholipids secretion

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

Passage of gallstones into the CBD

- Majority of bile duct stones are cholesterol stones from the gallbladder w/c migrated into the extrahepatic biliary tree via the cystic duct

Undetected duct stones left behind in cholecystectomy patients

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

PATHOGENESIS OF GALLSTONES

Obstructive Jaundice

Pancreatitis

Secondary Biliary Cirrhosis

• May be acute or chronic inflammation
• caused by at least partial obstruction to the flow of bile
• Bacteria are present on bile culture in 75% of patients
• CHARCOT’S TRIAD
• biliary pain
• jaundice
• spiking fevers with chills

• Nonsuppurativeacute cholangitis
• most common and respond rapidly to antibiotics
• Suppurative acute cholangitis
• Pus in completely obstructed ductal system  symptoms of severe toxicity such as mental confusion and septic shock
• Poor response to antibiotics and mortality is 100% unless prompt endoscopic or surgical relief of the obstruction and drainage of infected bile are carried out.

ERCP with endoscopic sphincterotomy

Biliary Obstruction

Increase intrabiliary pressure

Progressive dilation of intrahepcatic bile ducts

Suppressed hepatic bile flow

Reabsorption and regurgitation of conjugated bilirubin into the bloodstream

JAUNDICE, bilirubinuria, acholic stools

Biliary obstruction may be due to:

• complicates over 30% of Choledocholithiasis cases
• Due to passage of gallstones through the common duct
• Should be suspected in patients who develop:
• Back pain or pain to the left of the abdominal midline
• Prolonged vomiting with paralytic ileus
• Pleural effusion, especially on the left side
• Resolves upon surgical treatment of gallstones

• May complicate prolonged or intermittent duct obstruction with or without recurrent cholangitis
• More common in cases of prolonged obstruction from stricture or neoplasm
• May be progressive even after correction of the obstructing process

• Preoperative Cholangiography
• Endoscopic Retrograde Cholangiopancreatography (ERCP)
• Provides stone clearance
• Defines anatomy of biliary tree
• Intraoperative Cholangiography
• If patient undergoes cholecystectomy
• 15% patients undergoing cholecystectomy will prove to have CBD stones

ERCP and Laparoscopic cholecystectomy lowers the incidence of complications from choledocholithiasis.

Endoscopic Biliary Sphincterotomy followed by Spontaneous Passage or Stone Extraction

Lifestyle Changes

Obstructive Jaundice

In Comparison with the Clinical Presentation of Choledocholithiasis

Choledocholithiasis

In Comparison with the Clinical Presentation of Choledocholithiasis

Risk Factor For Choledocholithiasis – Primary Calculi arising de novo in ducts