Choledocholithiasis

Pathophysiology

Complications

Diagnosis

Treatment1

PATHOPHYSIOLOGY

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• 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 secretionHarrison’s Principles of Internal Medicine, 17th ed.

PATHOPHYSIOLOGY

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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. 4

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PATHOGENESIS OF GALLSTONES

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COMPLICATIONS

Cholangitis

Obstructive Jaundice

Pancreatitis

Secondary Biliary Cirrhosis

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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

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CHOLANGITIS

– Nonsuppurative acute 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 sphincterotomy9

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 10

• Biliary obstruction may be due to:

Choledocholithiasis Underlying MalignancyChronic calculous cholecystitisIndistensible gallbladder Distended, palpable

gallbladder

Serum bilirubin level >85.5 μmol/L but seldom over 256.5 μmol/L

Serum bilirubin level ≥342.0 μmol/L

Elevated serum alkaline phosphatase

Elevated serum alkaline phosphatase

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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

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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

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DIAGNOSIS AND MANAGEMENT

CHOLEDOCHOLITHIASIS

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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 stones15

MANAGEMENT

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

• Endoscopic Biliary Sphincterotomy followed by Spontaneous Passage or Stone Extraction

• Lifestyle Changes16

Patient’s History Ultrasound and Lab Findings

Jaundice• tea colored urine• icteric sclera

CBD size (12 mm) with dilated intrahepatic ducts

ALT

Alkaline Phosphatase

Total bilirubin

In Comparison with the Clinical Presentation of

Choledocholithiasis

Obstructive Jaundice17

Patient’s History Patient’s Ultrasound and Lab Findings

Jaundice• tea colored urine• icteric sclera

CBD size (12 mm) with dilated intrahepatic ducts

ALT

Alkaline Phosphatase

Total bilirubin

Choledocholithiasis

In Comparison with the Clinical Presentation of

Choledocholithiasis

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Patient’s History Ultrasound and Lab Findings

Jaundice• tea colored urine• icteric sclera

CBD size (12 mm) with dilated intrahepatic ducts

ALT

Alkaline Phosphatase

Total bilirubin

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

In Comparison with the Clinical Presentation of

Choledocholithiasis

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Patient’s History Ultrasound and Lab Findings

Jaundice• tea colored urine• icteric sclera

CBD size (12 mm) with dilated intrahepatic ducts

ALT

Alkaline Phosphatase

Total bilirubin

Choledocholithiasis as Differential Diagnosis

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THANK YOU!

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