CHOLEDOCOLITHIASIS

1. CASE PRESENTATION
DEPARTMENT OF SURGERY
SACRED HEART HOSPITAL
PRESENTED BY
DR. KALPANA SAH M.D.
PGI
12/29/2018 1

2. GENERAL DATA
• A case of R.C.O
• 34 y.o , female
• married, filipina
• roman catholic
• nurse
• living in bolinwan carcar city , cebu
12/29/2018 2

3. CHIEF COMPLAINT
•RIGHT UPPER QUADRANT PAIN
12/29/2018 3

4. HISTORY OF PRESENT ILLNESS
6 DAYS PTA
• Patient felt extreme pain on the epigastric area radaiting to the back
• (-) fever , (-) vomiting,
• Self medicated by ketorolac im , Temporary relief
5 DAYS PTA
• (+) persistent epigastric pain , Self medicated by ketorolac IM , pain tolerated
• ice tea colored urine
• Yellowish discoloration on her skin and sclera
4 DAYS PTA
• Sought consult to private physician
• Utz of whole abdomen was requested 12/29/2018 4

5. ULTRASOUND OF WHOLE ABDOMEN
(07/11/2016)
• GB intraluminal diameter: 2.8cm (N = < 4.0 cm)
• GB wall thickness : 0.3 cm ( N= < 0.4cm)
• Common duct : 1.1 cm ( N = < 0.6 cm)
• CBD is dilated with a 0.9 cm stone within
• Resultant mild ectasis of the intrahepatic biliary
radicles
• Within the non ectatic GB are multiple mobile
calculi ranging in size from 1.1 – 1.7 cm .
• The GB wall is not thickened.
• Liver is mildly enlarged
• Parenchymal echogenicity is mildly increased
Impression:
• Choledocolithiasis with resultant mild ectasia of the
intra hepatic biliary radicles
• Cholecystolithiasis
• Mild degree of fatty change with resultant mild
increase in liver dimension
•
12/29/2018 5

6. HISTORY OF PRESENT ILLNESS
3 DAYS PTA
• persistence of the condition
• Follow up with her physician for and was advised for surgical
management
ON THE DAY OF ADMISSION
• Pain persisted hence decided to be admitted
12/29/2018 6

7. PAST MEDICAL HISTORY
• Medical illness – none
• Medication – none
• Allergy – none
• Surgery – 2014 cesarean delivery CPD
2016 repeat cesarean delivery
• Hospitalization – 2014 and 2016
12/29/2018 7

8. PERSONAL / SOCIAL HISTORY
• Born and raised in carcar city
• Graduated bachelor of science in nursing on 2003
• Practising nurse at district hospital carcar city
• Been to abudhabi for 2years
• Living together with her husband and 3 children
• No history of alcohol beverage drink , non smoker
• No any history of illicit drug use
12/29/2018 8

9. FAMILY HISTORY
• Paternal – hypertensive
• Maternal – none
12/29/2018 9

10. OBSTETRICAL / MENSTRUAL HISTORY
• Patient is G4P3013
• G1 - 2004 - normal vaginal delivery
• G2 - 2011 - polyhydramnion result to death of 2nd baby,
• G3 - 2014 - cesarean delivery , cephalopelvic dispropotion
• G4 - 2016 – cesarean delivery and ligation, repeat c / s
• Menarcheage at age 12
• Regular menses ,
• Dysmenorrhea , 3 to 4 days duration
• Uses natural family planning method
• Ligated at MAY 2016
12/29/2018 10

11. PHYSICAL EXAM
General survey: Awake, Conscious, Coherent, Afebrile , Not
in any Distress
Vital signs:
• BP- 130/90 mmHg
• HR- 83 bpm
• RR- 21 cpm
• Temp- 36.6 0 C
• O2 sat- 97%
12/29/2018 11

12. PHYSICAL EXAM
• Skin: warm, good turgor, , (-) rashes
• HEENT : Icteric sclera, Pink palpebral conjunctiva, (-) nasal discharges
• C/L: Equal chest expansion, clear breath sounds
• CVS: Distinct heart sound, (-) murmur
• ABDOMEN: Flabby, soft, normoactive bowel sound, soft, (+) epigastric tenderness,
(+) murphy’s sign
• GUT: (-) Kidney Punch Sign
• EXTREMITY: strong peripheral pulse , good strength , Capillary Refill Time <2 sec,
Strong peripheral pulse
12/29/2018 12

13. IMPRESSION
• Acute calculous cholecystitis with choledocolithaisis
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14. ON DAY OF ADMISSION
• Low fat diet was advised
• Iv fluid venoclysis plain LR at 30 gtts/min
• Labs were taken: CBC,Blood typing, Prothrombin time, Alkaline
phosphate , U/A , NA , K , chest X ray PA-view
• Medication given cefoxitin (monomel) 1gm IVTT
• Patient was Reffered to IM for cp clearance
12/29/2018 14

15. CBC (07/14/2016)
CBC RESULT REF
WBC 5.8 x 103/mm3 4.4-11.0
NEU 57.7% x 103/mm3 37-80
LYM 27.7% x 103/mm3 10-50
MON 8.5 % x 103/mm3 0-12
EOS 5.6 % x 103/mm3 0-7
BAS 0.5% x 103/mm3 0-2.5
RBC 4.9 x 109/mm3 4.5-5.10
HGB 12.4 g/dl 12.3-15.3
HCT 39.6 % 35.9-44.6
MCV 95 pg 80-96
MCHC 31.2 g/dl 27.5- 33.2
RDW 11.4 % 11.6- 14.8
PLT 331 x 103/mm3 150-450
MPV 7.6 um3 6.0-11.0 12/29/2018 15

16. U/A (07/14/2016)
URINALYSIS RESULT REFERENCE
MACROSCOPIC EXAMINATION
COLOR DARK YELLOW
TRANSPARENCY HAZY
PH 6.5
SPECIFIC GRAVITY 1.010 1.003 – 1.035
CHEMICAL PROPERTIES:
PROTEIN (albumin) NEGATIVE NEGATIVE
LEUKOCYTES NEGATIVE
BLOOD / Hb 1+ NEGATIVE
MICROSCOPIC PROPERTIES:
WBC 3-6 / HPF 0-5/HPF
RBC 0-3 / HPF 0-2/HPF
BACTERIA ABUNDANT
EPITHELIAL CELL FEW
12/29/2018 16

17. CLINICAL CHEMISTRY (07/14/2016)
ANALYTE RESULT NORMAL RANGE RESULT NORMAL RANGE
CREATININE 0.63 mg/dL 0.51 – 0.95 55.7 umol/L 45.1 – 84.0
ALT (SGPT) 271 U/L , H <33 271 U/L <33
ALKALINE
PHOSPHATE
208 U/L , H 35.0 - 104.0 208 U/L 35.0 - 104.0
SODIUM 145.6 mmol/L, H 136.0 – 145.0 145.6 mmol/L 136.0 – 145.0
POTASSIUM 3.4 mmol/L , L 3.5 – 5.1 3.4 mmol/L 3.5 – 5.1
12/29/2018 17

18. COURSE IN WARD
Hospital Day 1 S O A P
07 /15 / 2016
Vital sign:
BP – 130/80 mmhg
PR – 81 bpm
RR- 21cpm
TEMP- 36.5 c
(+) epigastric pain
(-) vomiting, (-)
nausea, (-)
dizziness, good
urine output, sleep
well
Awake , concious,
coherent, not in
respiratory distress
Skin : warm , good
turgor, (+) pale
skin
Heent : icteric
sclerae, pinkish
conjuctiva
C/ L: equal chest
expansion, clear
breath sound
Abd : (+) RUQ
tenderness ,
Normoactive bowel
sound
Ext : strong pulse,
CRT <2 sec.
Patient is stable
with stable vital
sign
• Cefoxitin
•For schedule
operation
12/29/2018 18

19. COURSE IN WARD
Hospital Day 2 S O A P
07/16/ 2016
Vital sign:
BP – 130/70 mmhg
PR – 72 bpm
RR- 20 cpm
TEMP- 36.8 c
(+) epigastric pain
(-) vomiting, (-)
nausea, (-)
dizziness, good
urine output, sleep
well
Awake , concious,
coherent, not in
respiratory distress
Skin : warm , good
turgor, (+) pale
skin
Heent : icteric
sclerae, pinkish
conjuctiva
C/ L: equal chest
expansion, clear
breath sound
Abd : (+) RUQ
tenderness ,
Normoactive bowel
sound
Ext : strong pulse,
CRT <2 sec.
Patient is stable
with stable vital
sign
• Cefoxitin
• For schedule
operation
12/29/2018 19

20. COURSE IN WARD
Hospital Day 3 S O A P
07/17/ 2016
Vital sign:
BP – 130/70 mmhg
PR – 63 bpm
RR- 22 cpm
TEMP- 36.5 c
(+) epigastric pain
(-) vomiting, (-)
nausea, (-)
dizziness, good
urine output, sleep
well
Awake , concious,
coherent, not in
respiratory distress
Skin : warm , good
turgor, (+) pale
skin
Heent : icteric
sclerae, pinkish
conjuctiva
C/ L: equal chest
expansion, clear
breath sound
Abd : (+) RUQ
tenderness ,
Normoactive bowel
sound
Ext : strong pulse,
CRT <2 sec.
Patient is stable
with stable vital
sign
•NPO post
midnight
•Pantoprazole
40mg IVTT
•Metoclopromide
IVTT
12/29/2018 20

21. COURSE IN WARD
Hospital Day 4 S O A P
07/18/ 2016
Vital sign:
BP – 140/90 mmhg
PR – 85 bpm
RR- 20cpm
TEMP- 36.5 c
(+) epigastric pain
(-) vomiting, (-)
nausea, (-)
dizziness, good
urine output, sleep
well
Awake , concious,
coherent, not in
respiratory distress
Skin : warm , good
turgor, (+) pale
skin
Heent : icteric
sclerae, pinkish
conjuctiva
C/ L: equal chest
expansion, clear
breath sound
Abd : (+) RUQ
tenderness ,
Normoactive bowel
sound
Ext : strong pulse,
CRT <2 sec.
Patient is stable
with stable vital
sign
•Patient for OR
12/29/2018 21

22. SURGERY RECORD
• PREOP DIAGNOSIS : obstructive jaundice 2 to choledocholithaisis with
cholelithiasis
• Proposed operation : open cholecystectomy , IOC, choledochostomy,
common bile duct exploration , T – tube cholangiogram
• OPERATION PROCEDURE: open cholecystectomy with IOC , CBDE, T-
Tube cholangiogram
• POST OP DIAGNOSIS: obstructive jaundice 2 to choledocholithaisis with
cholelithiasis
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23. IOC PICTURE
12/29/2018 23

24. SPECIMEN
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25. POST OP MEDICATION
• Tramadol 50mg IVTT PRN
• Ketorolac 30mg IVTT q6hr x 4doses
• Tramadol 50mg IVTT q6hr x4doses
• Pantoprazole 40mg IVTT q 24hr
• Cefoxitin 1gm IVTT q8hr
12/29/2018 25

26. COURSE IN WARD
Hospital Day 5 S O A P
07/19/ 2016
Vital sign:
BP – 120/70 mmhg
PR – 83 bpm
RR- 23 cpm
TEMP- 36.5 c
T tube drainage-
170 cc
(+) pain at post op
site
(-) vomiting, (-)
nausea, (-)
dizziness, good
urine output, sleep
well
Awake , concious,
coherent, not in
respiratory distress
Skin : warm , good
turgor, (+) pale
skin
Heent : icteric
sclerae, pinkish
conjuctiva
C/ L: equal chest
expansion, clear
breath sound
Abd : (+) RUQ
tenderness ,
Normoactive bowel
sound
Ext : strong pulse,
CRT <2 sec.
Patient is stable
with stable vital
sign
• cbc
•Post op utz
•Tramadol 50mg
IVTT q6hr
x4doses
•Pantoprazole
40mg IVTT q 24hr
12/29/2018 26

27. CBC (07/19/2016)
CBC RESULT REF
WBC 12.9 x 103/mm3 H 4.4-11.0
NEU 83.5 % x 103/mm3 H 37-80
LYM 9.1 % x 103/mm3 10-50
MON 5.3 % x 103/mm3 0-12
EOS 1.8 % x 103/mm3 0-7
BAS 0.3 % x 103/mm3 0-2.5
RBC 4.05 x 109/mm3 4.5-5.10
HGB 12.1 g/dl 12.3-15.3
HCT 38.2 % 35.9-44.6
MCV 94 pg 80-96
MCHC 31.6 g/dl L 27.5- 33.2
RDW 11.4 % 11.6- 14.8
PLT 290 x 103/mm3 150-450
MPV 7.8 um3 6.0-11.0 12/29/2018 27

28. POST OP ULTRASOUND
• Liver –normal in size , shape and echotexture no mass detected no evidence of
intrahepatic biliary duct dilatation . The intrahepatic vascular markings are within
the limit is normal
• Gallbladder – no longer seeen due to previous cholecystectomy . The common
bile duct is normal in caliber.
• Impression :
• No evidence of intrahepatic cholangiectasia
• Normal common bile duct
• No stone detected
12/29/2018 28

29. COURSE IN WARD
Hospital Day 6 S O A P
07 /20 / 2016
Vital sign:
BP – 120/70 mmhg
PR – 75 bpm
RR- 21 cpm
TEMP- 36.5 c
T tube drainage-
150
(+)Pain at post op
site
(-) vomiting, (-)
nausea, (-)
dizziness, good
urine output, sleep
well
Awake , concious,
coherent, not in
respiratory distress
Skin : warm , good
turgor, (+) pale
skin
Heent : icteric
sclerae, pinkish
conjuctiva
C/ L: equal chest
expansion, clear
breath sound
Abd : (+) RUQ
tenderness ,
Normoactive bowel
sound
Ext : strong pulse,
CRT <2 sec.
Patient is stable
with stable vital
sign
•Tramadol 50mg
IVTT q6hr
x4doses
•Pantoprazole
40mg IVTT q 24hr
12/29/2018 29

30. COURSE IN WARD
Hospital Day 7 S O A P
07 /21/ 2016
Vital sign:
BP – 130/90 mmhg
PR – 79 bpm
RR- 22 cpm
TEMP- 36.5 c
(+) mild pain on
post op site
(-) vomiting, (-)
nausea, (-)
dizziness, good
urine output, sleep
well
Awake , concious,
coherent, not in
respiratory distress
Skin : warm , good
turgor
Heent : Anicteric
sclerae, pinkish
conjuctiva
C/ L: equal chest
expansion, clear
breath sound
Abd : (- ) RUQ
tenderness ,
Normoactive bowel
sound
Ext : strong pulse,
CRT <2 sec.
Patient is stable
with stable vital
sign
Ok for discharge
Take home
medication
-Cefuroxime
500mg BID
-Celecoxib 200mg
BID
12/29/2018 30

31. DISCUSSION
CHOLEDOCOLITHIASIS
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32. CHOLEDOCHOLITHIASIS
Common bile duct stones
• Small or large = single or multiple,
• Found in 6% to 12% of patients with stones in the GB
• The incidence increases with age.
12/29/2018 32

33. CHOLEDOCHOLITHIASIS
• Primary CBD Stones  that form in the bile ducts.
• Usually brown pigment typeassociated w/ biliary stasis & infection
• more commonly seen in Asian populations.
• The causes of biliary stasis that lead to the development of primary stones
include biliary stricture, papillary stenosis, tumors, or other (secondary) stones.
• Secondary CBD stones: formed within the gallbladder  migrate down the
cystic duct to the common bile duct.
• usually cholesterol stones
12/29/2018 33

34. CHOLEDOCHOLITHIASIS
• CLINICAL MANIFESTATIONS
• SILENT , often discovered incidentally.
• may cause obstruction, complete or incomplete, OR
• may manifest with cholangitis or gallstone pancreatitis.
• The PAIN of CBD Stone= also biliary colic (similar to cystic duct
stone)
• Jaundice , Nausea and vomiting are common.
12/29/2018 34

35. CHOLEDOCHOLITHIASIS
• PHYSICAL EXAMINATION
• may be normal, but mild epigastric or RUQ tenderness as well as
mild icterus are common.
• The symptoms – intermittent; pain and transient jaundice (temporarily
impacts the ampulla but subsequently moves away, acting as a ball
valve )
• CBD stone  pass through the ampulla spontaneously  resolution
OF Sx.
• become completely impacted severe progressive jaundice.
12/29/2018 35

36. DIAGNOSTIC STUDIES
ROUTINE Blood Tests :
• 1. CBC
• Increased WBC : raise suspicion of CHOLECYSTITIS.
• 2. LIVER FUNCTION TEST
• elevation of bilirubin, alkaline phosphatase, and aminotransferase, CHOLANGITIS
should be suspected.
• elevation of conjugated bilirubin & and a rise in alkaline phosphatase 
CHOLESTASIS. Serum aminotransferases may be normal or mildly elevated.
• In patients with biliary colic or chronic cholecystitis
• blood tests will typically be normal.
12/29/2018 36

37. INITIAL INVESTIGATIONS
2. Liver Function Test (LFT)
• Completely normal: NPV > 97%
• Abnormal: PPV 15%
• Bilirubin is the strongest predictor for CBD stones ; specificity
varies according to level
• Bilirubin ≥ 30 µmol/L: specificity 60%
• Bilirubin ≥ 68 µmol/L: specificity 75%
• Mean bilirubin in CBD stones: 25.5 – 32.3 µmol/L
12/29/2018 37

38. DIAGNOSTIC STUDIES
1. ULTRASONOGRAPHY= first test
• documenting stones in the GB (if still present)
• determining the size of the common bile duct
• A dilated common bile duct (>8 mm in diameter)
+ jaundice, and biliary  common bile duct stones.
12/29/2018 38

39. DIAGNOSTIC STUDIES
• ULTRASONOGRAPHY
Advantages:
• Initial investigation of GBD
• Noninvasive, painless, No radiation exposure
• can be performed on critically ill patients.
• Adjacent organs can frequently be examined at the same time.
Disadvantages
• Operator dependent
• Not satisfactory for Obese patients, patients with ascites & distended bowel
12/29/2018 39

40. DIAGNOSTIC STUDIES
• ULTRASONOGRAPHY
• GALLSTONE
• sensitivity and specificity of >90%)
• dense, acoustic shadow
• Move with changes in position
• POLYPS
• may be calcified reflect shadows
• do not move with change in posture.
Acoustic shadows from gall stones.
12/29/2018 40

41. DIAGNOSIS STUDIES
2. Magnetic resonance cholangiography (MRC) (pcs guidelines
2014)
• provides excellent anatomic detail
• sensitivity and specificity of 95% and 89%
• detecting choledocholithiasis >5 mm in diameter
3. Endoscopic cholangiography
• GOLD STANDARD FOR DIAGNOSING COMMON BILE DUCT
STONES.
• distinct advantage : THERAPEUTIC OPTION at the time of
diagnosis.
12/29/2018 41

42. DIAGNOSTIC STUDIES
4. ORAL CHOLECYSTOGRAPHY
• OLD DAYS : diagnostic procedure of choice for gallstones,
• Replaced by ultrasonography.
• oral administration of a radiopaque compound
• absorbed, excreted by the liver, and passed into the GB.
• Stones are noted on a film as FILLING DEFECTS in a
visualized, opacified gallbladder.
• Oral cholecystography is of no value in:
• patients with intestinal malabsorption
• vomiting, obstructive jaundice, and hepatic failure.
STONE FILLING DEFECTS
12/29/2018 42

43. DIAGNOSTIC STUDIES
5. BILIARY RADIONUCLIDE SCANNING (HIDA SCAN)
• noninvasive evaluation of the liver, gallbladder, bile ducts, and
duodenum with both anatomic and functional information
• dimethyl iminodiacetic acid (HIDA) are injected intravenously, cleared
by the Kupffer cells in the liver, and excreted in the bile.
• Uptake by the liver : 10 minutes
• GB, bile ducts & the duodenum : visualized within 60 minutes
(fasting)
12/29/2018 43

44. DIAGNOSTIC STUDIES
• PRIMARY USE : diagnosis of ACUTE CHOLECYSTITIS,
• appears as a nonvisualized gallbladder AFTER 4 HOURS with
prompt filling of the common bile duct and duodenum
• Evidence of cystic duct obstruction ?acute cholecystitis.
• Biliary leaks as a complication of surgery can be identified.
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45. • Normal cholescintigrams
normal gallbladder filling
within 45 minutes. No filling of the gallbladder
cystic duct obstruction.
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46. DIAGNOSTIC STUDIES
6. COMPUTED TOMOGRAPHY
• Inferior to UTZ in diagnosing gallstones.
• TEST OF CHOICE in evaluating
• suspected MALIGNANCY of the gallbladder,
the extrahepatic biliary system, head of the
pancreas.
• Spiral CT scanning provides additional staging
information, including vascular involvement in
patients with periampullary tumors
CT scan shows pearl gallstones and
thickening of the gallbladder wall.
12/29/2018 46

47. DIAGNOSTIC STUDIES
7. PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY (PTC)
• Intrahepatic bile ducts are accessed percutaneously with a small needle
under fluoroscopic guidance.
• Once the position in a bile duct has been confirmed, a guidewire is
passed, and subsequently, a catheter is passed over the wire
• Through the catheter, a cholangiogram can be performed and therapeutic
interventions done, such as biliary drain insertions and stent placements.
12/29/2018 47

48. DIAGNOSTIC STUDIES
PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY (PTC)
• little role in the uncomplicated gallstone disease
• particularly useful in patients with BILE DUCT STRICTURES AND
TUMORS defines the anatomy of the biliary tree proximal to the
affected segment.
• potential risks
• bleeding, cholangitis, bile leak
12/29/2018 48

49. DIAGNOSTIC STUDIES
BILE DUCT STRICTURESPERCUTANEOUS TRANSHEPATIC
CHOLANGIOGRAPHY (PTC)
12/29/2018 49

50. DIAGNOSTIC STUDIES
8. MAGNETIC RESONANCE IMAGING
• MRI provides ANATOMIC DETAILS of the liver, gallbladder,
and pancreas similar to those obtained from CT.
• can generate high-resolution anatomic images
• sensitivity and specificity of 95% and 89% respectively, at
detecting choledocholithiasis.
• MAGNETIC RESONANCE
CHOLANGIOPANCREATOGRAPHY (MRCP)
• offers a single noninvasive test for the diagnosis of biliary tract
and pancreatic disease
course of the extrahepatic bile ducts
(arrow) and
pancreatic duct (arrowheads).
12/29/2018 50

51. DIAGNOSTIC STUDIES
9. ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATOGRAPHY (ERCP)
• Using a side-viewing endoscope, the common bile duct
can be cannulated and a cholangiogram performed
using fluoroscopy
• requires intravenous (IV) sedation for the patient.
12/29/2018 51

52. ERCP
• The ADVANTAGES OF ERC include
• direct visualization of the ampullary region
• direct access to the distal common bile duct, with the possibility of
therapeutic intervention.
• ERC is the diagnostic and often therapeutic procedure of choice.
• Once the endoscopic cholangiogram has shown ductal stones,
sphincterotomy and stone extraction can be performed, and the
common bile duct cleared of stones
12/29/2018 52

53. DIAGNOSTIC STUDIES
• ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATOGRAPHY (ERCP)
• SUCCESS RATE of common bile duct cannulation
and cholangiography >90%.
• COMPLICATIONS of diagnostic ERC
• pancreatitis and cholangitis (5%)
• considered safe
• THERAPEUTIC APPLICATIONS
• biliary stone lithotripsy & extraction in high-risk
surgical patients
12/29/2018 53

54. ENDOSCOPIC RETROGRADE CHOLANGIOGRAPHY.
A. A schematic picture showing the side-viewing
endoscope in the DUODENUM and a catheter in
the common bile duct.
B. An endoscopic cholangiography showing stones in the
COMMON BILE DUCT. The catheter has been placed in
the ampulla of Vater (arrow). Note the duodenal
shadow indicated with arrowheads.
12/29/2018 54

55. DIAGNOSTIC STUDIES
10. ENDOSCOPIC ULTRASOUND
• special endoscope with an ultrasound transducer at its tip.
• operator dependent, but offer noninvasive imaging of the bile ducts and
adjacent structures.
• Of particular value in the EVALUATION OF TUMORS & their
RESECTABILITY.
• The ultrasound endoscope has a BIOPSY CHANNEL
• needle biopsies of a tumor under ultrasonic guidance
• Can identify bile duct stones
• less sensitive than ERC
• less invasive as cannulation of the sphincter of Oddi is not necessary for
diagnosis of choledocholithiasis 12/29/2018 55

56. ENDOSCOPIC ULTRASOUND
12/29/2018 56

57. DIAGNOSTIC STUDIES
ENDOSCOPIC ULTRASOUND
EUS demonstrating a small stone (arrowed) within the
common bile duct that was not observed on MRCP
12/29/2018 57

58. TREATMENT AND
MANAGEMENT
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59. 12/29/2018 59

60. TREATMENT
1. Cholecystostomy
2. Cholecystectomy
3. Laparoscopic Cholecystectomy
4. Open Cholecystectomy
5. Choledochoduodenostomy (pcs guidelines ,2014)
• Least recurrence
12/29/2018 60

61. TREATMENT
1. Cholecystostomy
• Decompresses and drains the
distended inflamed, hydropic, or
purulent gallbladder.
• applicable if the patient is not fit to
tolerate an abdominal operation.
• Ultrasound-guided percutaneous
drainage with a pigtail catheter is
the procedure of choice.
12/29/2018 61

62. ERCP
1. ERCP
2. 24 TO 48 HOURS
12/29/2018 62

63. CHOLEDOCHOLITHIASIS
TREATMENT
• Symptomatic gallstones + suspected common bile duct stones, either
:
• preoperative endoscopic cholangiography or
• intraoperative cholangiogram
• If an ENDOSCOPIC CHOLANGIOGRAM  reveals stones
• sphincterotomy and ductal clearance of the stones is appropriate,
• followed by a laparoscopic cholecystectomy.
12/29/2018 63

64. TREATMENT
• An INTRAOPERATIVE CHOLANGIOGRAM (IOC)
• at the time of cholecystectomy
• will also document the presence or absence of bile duct stones
• Open common bile duct exploration
• option if the endoscopic method is not feasible
• AMPULLARY STONES  CBD >2cm, CBDE/Endoscopy are difficult.
• choledochoduodenostomy OR
• a Roux-en-Y choledochojejunostomy
12/29/2018 64

65. TREATMENT
• RETAINED STONES
• ERCP- confirmed retained CBD stones, treat with ERCP.
• stones deliberately left in place at the time of surgery
• retrieved either endoscopically or via the T-tube tract once it has matured (2–4
weeks).
• RECURRENT STONES
• diagnosed months or years later, multiple& large
• endoscopic sphincterotomy  stone retrieval
• Retained or recurrent stones following cholecystectomy are best treated
ENDOSCOPICALLY
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66. COMMON BILE DUCT DRAINAGE PROCEDURES
• Rarely, when the stones cannot be
cleared and/or when the duct is very
dilated (>1.5 cm in diameter), a
choledochal drainage procedure is
performed
• Choledochoduodenostomy is
performed by mobilizing the second
part of the duodenum (a Kocher
maneuver) and anastomosing it side
to side with the common bile duct.
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67. COMMON BILE DUCT DRAINAGE PROCEDURES
• A choledochojejunostomy is done by
bringing up a 45-cm Roux-en-Y limb of
jejunum and anastomosing it end to side to
the common bile duct.
• Choledochojejunostomy or, more often, a
hepaticojejunostomy, also can be used to
repair common bile duct strictures or as a
palliative procedure for malignant
obstruction in the periampullary region. If
the common bile duct has been transected
or injured, it can be managed by an end-to-
end choledochojejunostomy
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68. TRANSDUODENAL SPHINCTEROTOMY
• Endoscopic sphincterotomy has replaced open transduodenal sphincterotomy.
• Open procedure - stones are impacted, recurrent, or multiple, the transduodenal
approach may be feasible.
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69. COMPLICATION
Two main complications of choledochal stones:
1. Cholangitis
2. Gallstone pancreatitis.
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70. HISTOPATH
• FINAL DIAGNOSIS – CHOLEDOCOLITHIASIS
• Gallbladder measure 6.5 x 2.0 x 1.5 cm
• Opening reveals several stones measuring from 1.0 to 1.5cm in greater dimension
• Mucosa is green brown and fibrotic
• Wall measures 0.3 cm thick
• Microscopic examination – lympho plasmacytic infiltration of the edematous and partly fibrotic gallbladder
wall and mucosa
• Gallbladder mucosa is mostly effaced with area
• The walls show few glands lined by columnar epithelium cells with basal nuclei
• No atypia is seen.
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71. End of slide
Thank you for listening
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72. TREATMENT CHOLANGITIS (pcs guidelines 2014)
Cholangitis
• Ciprofloxacin 200mgs IV BID or Ceftazidime 1gm IV BID + Ampicillin 500mgs IV QID +
Metronidazole 500mgs IV TID (Level 1B, Category B)
Alternative
• Piperacillin + an Aminoglycoside + Metronidazole or Piperacillin-Tazobactam or Ampicillin-
Sulbactam or Ticarcillin
Severe cholangitis
• Non-operative biliary drainage (endoscopic).
• If endoscopic drainage is not available or is not successful, percutaneous transhepatic
biliary drainage (PTBD) or surgical decompression are the recommended alternatives.
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