choledocholithiasis- obstructive jaundice
Post on 12-Jan-2017
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OBSTRUCTIVE JAUNDICE
Dr.B.Selvaraj MS;Mch;FICS;Professor Of Surgery
Melaka Manipal Medical collegeMelaka 75150 Malaysia
CHOLEDOCHOLITHIASIS
Choledocholithiasis- Overview
Causes of obstructive jaundiceClassical clinical vignetteEtiopathogenesisClinical features & complicationsInvestigationsTreatmentMindmap of CholedocholithiasisDiagnostic Algorithm in obstructive jaundiceManagement algorithm in choledocholithiasis
Obstructive Jaundice- Causes
• Intraluminal causes: - Choledocholithiasis - Clonorchis sinensis - Ascariasis & Schitosomiasis• Mural causes: - Malignant stricture-cholangiocarcinoma - Benign stricture- Scelerosing cholangitis• Extrinsic Causes: - Ca Head of Pancreas - Periampullary Carcinoma, Portal LN
Classical Clinical Vignette
A 40-year-old female presents with a 24 hour history of right upper quadrant (RUQ) and epigastric pain, associated with nausea and vomiting. She has had similar pain in the past, particularly after eating fatty foods. According to her family, over the last few hours, the patient has become slightly confused. Past medical history is negative.
O/E: She is moderately tender in the RUQ to deep palpation. She has slight scleral icterus. She has noted dark- coloured urine. The remainder of her abdominal exam is negative.
Vitals: BP-90/60 mms of Hg; PR-110/mt; RR-16/mt;T:102*F
Classical Clinical Vignette
Laboratory examination: TWBC- 15,000/μL(4 to 11,000/μL), Total bilirubin-4mgm/dl(0.1 to 1.2mgm/dl) Direct bili- 3mgm/dl ALP- 350μ/L (33-131μ/L); GGT- 330μ/L (8-88μ/L) AST- 300μ/L(5-35μ/L); ALT- 280μ/L(7-56μ/L) Sr Amylase- 100μ/L( 30-110μ/L)Urine is positive for bilirubin
CHOLEDOCHOLITHIASIS WITH CHOLANGITIS
Choledocholithiasis-Etiology
It is stones in the CBD and biliary tree.Primary—Rare 5%—brown pigment stones. They are formed in
CBD and biliary tree itself, and are multiple, often sludge like, commonly pigment or mixed type, extends into hepatic ducts.
Causes: Biliary stasis, biliary dyskinesia, caroli’s disease, choledochal cyst, clonorchiasis, ascariasis EtcSecondary—Common 95%—black pigment stones/cholesterol
stones. It is seen in 15% of gallstone disease; 75% are cholesterol stones, 25% are pigment stones.
Choledocholithiasis-Etiology
Clinical Features
50% asymptomaticBiliary colic because of CBD obstruction by
stone- pain in RHC & epigastrium Intermittent chills, fever, or jaundice
accompanies biliary colic Charcot’s triad Ascending cholangitis
Suppurative cholangitis Reynold’s pentad Persistent pain, fever, jaundice, shock & AMS
Painful jaundice with dark color urine, clay colored stool and pururitus.
Features of Ac Pancreatitis in distal CBD stone impaction
Clinical Features
Patient may be icteric and toxic, with high fever and chills, or may appear to be perfectly healthy.
A palpable gallbladder is unusual in patients with obstructive jaundice from common duct stone because the obstruction is transient and partial, and scarring of the gallbladder renders it inelastic and non distensible.
Courvoisier’s Law: “ In a jaundiced patient if GB is palpably enlarged it is not due to Gall stone”
Tenderness in the right upper quadrant is not often as marked as in acute cholecystitis, DU perforation or Ac Pancreatitis
Tender enlarged liver +
Differential diagnosis
Obstructive jaundice due to other causes:Carcinoma of head of pancreas Periampullary carcinomaCarcinoma of biliary tree- cholangiocarcinomaBiliary stricture- Scelerosing cholangitisIntrahepatic cholestasis from drugs, pregnancy, chronic active
hepatitis, or primary biliary cirrhosis may be difficult to distinguish from extrahepatic obstruction. ERCP would be appropriate to make the distinction.
COMPLICATIONS Liver dysfunction and biliary
cirrhosis. White bile formation and liver
failure. Suppurative cholangitis.Liver abscess. Septicaemia. Pancreatitis if CBD stone is near
sphincter of Oddi blocking drainage of bile and pancreatic duct.
Investigations- Labs
In cholangitis, leukocytosis of 15,000/mL is usual, and values above 20,000/mL are common.
T bilirubin level usually remains under 10 mg/dL, and most are in the range of 2-4 mg/dL. The direct fraction exceeds the indirect, but the latter becomes elevated in most cases.
Bilirubin levels do not ordinarily reach the high values seen in malignant tumors because the obstruction is usually incomplete and transient. In fact, fluctuating jaundice is so characteristic of choledocholithiasis.
Serum alkaline phosphatase & GGT levels usually risesMild increases in AST and ALT are often seen
Investigations-Imaging
AXR & USG abdomen- ineffective to pick up CBD stones USG abdomen may indicate dilated CBD >1cm CECT- can pick up CBD stone MRCP- best non-invasive diagnostic investigation ERCP- Gold standard- diagnostic & therapeutic EUS- can pick up CBD stone and can take biopsy if there is a
mass
Investigations-Imaging
ERCP MRCP
TREATMENT In absence of cholangitis:ERCP, Sphincterotomy, CBD stone removal by dormia basket or
balloon followed by Lap cholecystectomy.Lap cholecystectomy with Lap CBD exploration In presence of cholangitis:ERCP with sphincterotomy and stone extraction or stent
placement-decompression PTBD- Percutaneous transhepatic biliary drainage in ERCP failed
casesSurgical treatment: Only when above two procedures not possible. Decompression of CBD with T tube.
TREATMENT
TREATMENT Open cholecystectomy, intra op cholangiogram,
choledocholithotomy with T tube placement. Remove T tube—10 to 14 days after T tube cholangiogramMissed/retained/residual stones (< 2 years): If T tube present Percutaneous stone extraction via T tube tract
after 4-6 weeks (Burhenne technique) using choledochoscopeIf T tube absent ERCP stone removalRecurrent stones (> 2 years):ERCP—first approachIf duct dilated > 2 cm—choledochoduodenostomy or transduodenal sphincteroplasty
TREATMENTBurhenne Technique
Cholelithiasis Vs Choledocholithiasis
Choledocholithiasis - Mindmap
Obstructive Jaundice- Diagnostic Algorithm
Choledocholithiasis Treatement Algorithm
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