Choledocholithiasis. Pathophysiology Complications Diagnosis Treatment. Pathophysiology. PATHOPHYSIOLOGY. Primary formation of stones in the CBD *Primary calculi arising de novo in the ducts are usually pigment stones developing in patients with:
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Choledocholithiasis Pathophysiology Complications Diagnosis Treatment
PATHOPHYSIOLOGY 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.
PATHOPHYSIOLOGY 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.
Cholangitis Obstructive Jaundice Pancreatitis Secondary Biliary Cirrhosis COMPLICATIONS
CHOLANGITIS • 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
CHOLANGITIS • 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
OBSTRUCTIVE JAUNDICE 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
PANCREATITIS • 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
SECONDARY BILIARY CIRRHOSIS • 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
CHOLEDOCHOLITHIASIS Diagnosis and MANAGEMENT
DIAGNOSIS • 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
MANAGEMENT ERCP and Laparoscopic cholecystectomy lowers the incidence of complications from choledocholithiasis. Endoscopic Biliary Sphincterotomy followed by Spontaneous Passage or Stone Extraction Lifestyle Changes
In Comparison with the Clinical Presentation of Choledocholithiasis 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