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Intrahepatic stones Causes. Migration of gallbladder stones Proximal to common bile duct strictures Caroli’s disease Recurrent pyogenic cholangitis. Recurrent pyogenic cholangitis Pathology. Portal bacteraemia  acute cholangiolitis Transmural inflammation  biliary stricture

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intrahepatic stones causes
Intrahepatic stonesCauses
  • Migration of gallbladder stones
  • Proximal to common bile duct strictures
  • Caroli’s disease
  • Recurrent pyogenic cholangitis
recurrent pyogenic cholangitis pathology
Recurrent pyogenic cholangitisPathology
  • Portal bacteraemia  acute cholangiolitis
  • Transmural inflammation  biliary stricture
  • Biliary stasis  stones formation

further acute cholangitis

cholangitic liver abscesses

  • Parenchymal destruction  liver atrophy
  • Cholangiocarcinoma
slide14

40

30

Number of patients

20

10

0

0

10

20

30

40

50

60

70

80

90

100

Age

Age distribution by decades

Represented patients with previous biliary operations

Fan ST, Surgery, 1991

recurrent pyogenic cholangitis presentation
Recurrent pyogenic cholangitisPresentation
  • Acute cholangitis 60%
  • Acute pancreatitis
  • Jaundice
  • Hepatomegaly
  • Portal hypertension
recurrent pyogenic cholangitis treatment of acute cholangitis by conservative treatment
Recurrent pyogenic cholangitisTreatment of acute cholangitis by conservative treatment
  • Failure in 30%
  • Failure is often due to persistent obstruction in the common bile duct
slide17
Recurrent pyogenic cholangitisAcute cholangitisOrder of preference of biliary decompression for failure of conservative treatment

Endoscopic drainage

Radiological drainage

Emergency surgery

surgical treatment in acute phase decompression of biliary tract
Surgical treatment in acute phaseDecompression of biliary tract
  • Common bile duct exploration, T-tube drainage
  • Transhepatic tube drainage for patients with intrahepatic stricture and stones
cholangiogram finding of rpc
Cholangiogram finding of RPC
  • Loss of parallelism of ductal wall
  • Excessive branching of intrahepatic ducts
  • Arrow-head formation of small ducts
  • Strictures
  • Stones
operations in quiescent phase category of severity of rpc
Operations in quiescent phaseCategory of severity of RPC
  • Simple versus complicated cases
  • Complicated cases are those with intrahepatic duct stricture(s)
operation in quiescent phase simple cases
Operation in quiescent phaseSimple cases
  • Common duct exploration
  • Choledochoscopy
  • Choledochojejunostomy
    • for dilated and thick wall CBD
    • for unimpeded passage of newly formed stones into jejunum
operations in quiescent phase complicated cases
Operations in quiescent phaseComplicated cases
  • Hepaticocutaneous jejunostomy
  • Stricturoplasty
  • Partial hepatectomy
hepaticocutaneous jejunostomy
Hepaticocutaneous jejunostomy
  • For repeated or unlimited access to the biliary tract by choledochoscopy
  • Reopening of stoma for recurrence of stones and strictures
electrohydraulic lithotripsy indications
Electrohydraulic lithotripsyIndications
  • Large impacted stone
  • Stones behind stricture
recurrent pyogenic cholangitis partial hepatectomy indications
Recurrent pyogenic cholangitisPartial hepatectomy - Indications
  • Destroyed liver segment
  • Multiple cholangitic liver abscesses
  • Concomitant cholangiocarcinoma
results of current treatment
Results of current treatment
  • Hepaticocutaneous jejunostomy
    • hospital mortality 0%
    • morbidity 10%
  • Hepatectomy
    • hospital mortality 2%
    • morbidity 32%
  • Recurrence of stones
    • simple cases 10%
    • complicated cases 29%
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Recurrent Pyogenic Cholangitis

Gallbladder

Intrahepatic Duct Stone

Stricture of Left Hepatic Duct

Common Bile Duct

Stone

Duodenum

slide51

Gallbladder Stone Disease

Cystic-

duct

Gallbladder

Common Bile Duct

Stone

Stone

Duodenum