GROUP C
Salazar, Riccel
Salcedo, Von
Saldana, Emmanuel
Sales, Maria Stephanie
Salonga, Cryscel
September 21, 2009
Choledocholithiasis occurs as a result of either
the primary formation of stones in the
common bile duct (CBD) or the passage of
gallstones from the gallbladder through the
cystic duct into the CBD.
http://www.nlm.nih.gov/medlineplus/ency/article/000274.htm
Majority of the bile duct stones are
cholesterol stones formed in the gallbladder
which then migrates into the exrahepatic
biliary tree through the cystic duct
[secondary ]
Obstruction of the CBD by gallstones leads to
symptoms and complications that include
pain, jaundice, cholangitis, pancreatits and
sepsis.
Harrison’s Principles of Internal Medicine 17th ed p.1999
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1. Hepatobiliary parasitism or chronic,
recurrent cholangitis
2. Congenital anomalies of the bile ducts
3. Dilated or sclerosed or strictured ducts
4. MD3 gene defect leading to impaired
biliary phospholipids secretion
Harrison’s Principles of Internal Medicine 17th ed p.1999
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1. Cholesterol stones
2. Black pigment stones
3. Brown pigment stones
Secondary stones are those who were formed
in the gallbladder and later on migrate into
the CBD
Age
• 25% of elderly
patients may
have calculi in
the CBD
Previous History of
Gallstones
• Undetected duct
stones are left
behind in ~1-5%
of
cholecystectomy
patients
Infection with
parasites
• Ascaris
Lumbricoides
• Clonorchis
sinensis
http://www.nlm.nih.gov/medlineplus/ency/article/000274.htm
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Can be completely asymptomatic
Symptoms usually do not occur unless the
stone blocks the common bile duct
Symptoms and signs usually present as
 RUQ abdominal pain
 Jaundice
 Fever
 Tea colored urine
 Acholic stools
 Nausea and or Vomiting
Presentation
• Pain in RUQ or MUQ
• Sharp, cramping or
dull
• Pain radiating to the
back or below the
scapula
• Pain worsening after
eating fatty/greasy
food
Patient
• In our Patient:
• - Denies of having
abdominal pain
• [But
choledocholelithiasis
can present as a
painless jaundice]
Presentation
• Painless jaundice may
occur in patients with
cholelithiasis
• -caused by increased
bilirubin in the blood
• - post
hepatic/obstructive
jaundice
• Initially presents as
Icteric sclera
Patient
• Positive for jaundice
Presentation
Patient
• signifies post
hepatic cause
of jaundice
[Obstructive
Jaundice]
• Positive for
Tea/Dark
Colored urine
• Patient denies
acholic stools
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May be acute or chronic
Symptoms result from inflammation
 Caused by partial obstruction to the flow of bile
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Presence of bacteria in the bile culture in 75%
of patients with acute cholangitis early in the
symptomatic course
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CHARCOT’S TRIAD
 Characteristic presentation of acute cholangitis
 Biliary pain, jaundice and spiking fever with
chills
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Blood cultures are frequently positive, and
leukocytosis is typical
Nonsuppurative acute cholangitis
 Most common and may respond relatively rapidly
to supportive measures and to treatment with
antibiotics
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Suppurative acute cholangitis
 Presence of pus under pressure in a completely
obstructed ductal system leads to symptoms of
toxicity
▪ REYNOLDS PENTAD
▪ Mental confusion and septic shock
▪ Biliary pain, jaundice and spiking fever with chills
 Response to antibiotics is poor
 Multiple hepatic abscesses are present
 Mortality rate approaches 100%
▪ Endoscopic or surgical relief of the obstruction and
drainage of the infected bile
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Endoscopic management
 Effective as surgical intervention
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ERCP with endoscopic sphincterotomy
 Preferred initial procedure for both establishing a
definitive diagnosis and providing effective
therapy
 Safe
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Gradual obstruction of the CBD  jaundice or
pruritus without associated symptoms of
biliary colic or cholangitis
Painless jaundice
Associated chronic calculous cholecystitis is
very common
Absence of a palpable gallbladder
Biliary obstruction causes progressive
dilatation of the intrahepatic bile ducts
Hepatic bile flow is suppressed
Reabsorption and regurgitation of
conjugated bilirubin into the
bloodstream
Jaundice, dark urine (bilirubinuria),
light-colored (acholic) stools
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CBD stones should be suspected in any
patient with cholecystitis whose serum
bilirubin level is >85.5 mol/L (5 mg/dL)
Maximum bilirubin level is seldom >256.5
mol/L (15.0 mg/dL) in patients with
choledocholithiasis
Serum alkaline phosphatase level is almost
always elevated
May be a two- to tenfold elevation of serum
aminotransferases, especially in association
with acute obstruction
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Most common associated entity discovered
in patients with nonalcoholic acute
pancreatitis is biliary tract disease
Complicates:
 acute cholecystitis: 15%
 Choledocholithiasis: >30%
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Common factor appears to be the passage of
gallstones through the common duct
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Coexisting pancreatitis should be suspected
in patients with symptoms of cholecystitis
who develop:
 back pain or pain to the left of the abdominal
midline
 prolonged vomiting with paralytic ileus
 a pleural effusion, especially on the left side
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Surgical treatment of gallstone disease is
usually associated with resolution of the
pancreatitis
May complicate prolonged or intermittent duct
obstruction with or without recurrent cholangitis
 May be progressive even after correction of the
obstructing process
 Increasingly severe hepatic cirrhosis may lead to
portal hypertension or to hepatic failure and
death
 May also be associated with clinically relevant
deficiencies of the fat-soluble vitamins A, D, E,
and K
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Laboratory studies
Imaging studies
 Ultrasonography
 MRC
 Endoscopic cholangiography
Not specific for the diagnosis of choledocholithiasis
Increase in serum bilirubin, alkaline phosphatase,
gamma-glutamyl transpeptidase
 Moderate elevations on aminotranferases
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Ultrasonography
•Commonly the first test
•Useful for documenting stones in the
gallbladder and determining the size of the
common bile duct (90% accuracy).
Shows a dilated common bile duct (>8
mm in diameter) in a patient with
gallstones, jaundice, and biliary pain highly suggestive of common bile duct
stones.
•Detection of CBD stones is impeded by
the presence of gas in the duodenum,
possible reflection and refraction of the
sound beam by curvature of the duct, and
the location of the duct beyond the
optimal focal point of the transducer
MAGNETIC RESONANCE
CHOLANGIOGRAPHY
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Very accurate in the detection of
biliary tree obstruction and
ductal
dilatation,
both
intrahepatic and extrahepatic.
Has a sensitivity of 75-90% in the
detection of CBD stones, which
makes it an essential tool in the
evaluation of patients with
jaundice.
Capable of defining the level of
the obstruction and provides
information
about
the
surrounding
structures,
especially the pancreas.
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Provides excellent anatomic
detail and has a sensitivity and
specificity of 95 and 89%,
respectively, at detecting
choledocholithiasis
Cost, inconvenience, and
limitations (eg, obesity, presence
of metal objects, eg,
pacemakers) are some of its
disadvantages.
Gold standard for diagnosing common bile duct
stones
 Has a distinct advantage of providing a therapeutic
option at the time of diagnosis
 The CBD is cannulated through the ampulla,
contrast material is injected, and films are obtained.
The experience of the endoscopist is the best
predictor of success, which is 90-95% in expert
hands.
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Endoscopic
Cholangiography
ERC from the
same patient
shows multiple
stones in the
common bile
duct. Only the top
one showed on
ultrasound, as the
other stones lie in
the distal
common bile duct
behind the
duodenum.
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Medical
 ERCP
 Percutaneous extraction
 Extracorporeal shock wave lithotripsy
Surgical
 Open choledochotomy
 Transcystic exploration
 Drainage procedures
▪ Transduodenal sphincteroplasty
▪ Choledochoduodenostomy
▪ Choledochojejunostomy
 Cholecystectomy
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Patients with symptomatic gallstones and suspected
common bile duct stones, either preoperative endoscopic
cholangiography or an intraoperative cholangiogram will
document the bile duct stones.
If an endoscopic cholangiogram reveals stones,
sphincterotomy and ductal clearance of the stones is
appropriate, followed by a laparoscopic cholecystectomy.
An intraoperative cholangiogram at the time of
cholecystectomy will also document the presence or
absence of bile duct stones
Laparoscopic common bile duct exploration via the cystic
duct or with formal choledochotomy allows the stones to be
retrieved in the same setting.
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An open common bile duct exploration is an option if the
endoscopic method has already been tried or is for some
reason not feasible.
If a choledochotomy is performed, a T tube is left in place.
Stones impacted in the ampulla may be difficult for both
endoscopic ductal clearance as well as common bile duct
exploration (open or laparoscopic).
 In these cases the common bile duct is usually quite
dilated (about 2 cm in diameter).
 Choledochoduodenostomy
 Roux-en-Y choledochojejunostomy
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Harrison’s Principles of Internal Medicine, 17th
ed.
http://www.nlm.nih.gov/medlineplus/ency/ar
ticle/000274.htm