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Choledocholithiasis- obstructive jaundice

Choledocholithiasis is one of the main causes for Obstructive Jaundice.In this ppt presentation, I have discussed the etiology, clinical features, complications, investigations and management of Choledocholithiasis. I have also included a mindmap and 2 algorithms for Choledocholithiasis. I hope you will find it very useful and interesting.

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Choledocholithiasis- obstructive jaundice

  1. 1. OBSTRUCTIVE JAUNDICE Dr.B.Selvaraj MS;Mch;FICS; Professor Of Surgery Melaka Manipal Medical college Melaka 75150 Malaysia CHOLEDOCHOLITHIASIS
  2. 2. Choledocholithiasis- Overview Causes of obstructive jaundice Classical clinical vignette Etiopathogenesis Clinical features & complications Investigations Treatment Mindmap of Choledocholithiasis Diagnostic Algorithm in obstructive jaundice Management algorithm in choledocholithiasis
  3. 3. 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
  4. 4. 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
  5. 5. 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
  6. 6. 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 Etc Secondary—Common 95%—black pigment stones/cholesterol stones. It is seen in 15% of gallstone disease; 75% are cholesterol stones, 25% are pigment stones.
  7. 7. Choledocholithiasis-Etiology
  8. 8. Clinical Features 50% asymptomatic Biliary 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
  9. 9. 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 +
  10. 10. Differential diagnosis Obstructive jaundice due to other causes: Carcinoma of head of pancreas  Periampullary carcinoma Carcinoma of biliary tree- cholangiocarcinoma Biliary stricture- Scelerosing cholangitis Intrahepatic 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.
  11. 11. 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.
  12. 12. 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 rises Mild increases in AST and ALT are often seen
  13. 13. 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
  14. 14. Investigations-Imaging ERCP MRCP
  15. 15. 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 cases Surgical treatment: Only when above two procedures not possible. Decompression of CBD with T tube.
  16. 16. TREATMENT
  17. 17. TREATMENT  Open cholecystectomy, intra op cholangiogram, choledocholithotomy with T tube placement.  Remove T tube—10 to 14 days after T tube cholangiogram Missed/retained/residual stones (< 2 years): If T tube present Percutaneous stone extraction via T tube tract after 4-6 weeks (Burhenne technique) using choledochoscope If T tube absent ERCP stone removal Recurrent stones (> 2 years): ERCP—first approach If duct dilated > 2 cm—choledochoduodenostomy or transduodenal sphincteroplasty
  18. 18. TREATMENT Burhenne Technique
  19. 19. Cholelithiasis Vs Choledocholithiasis
  20. 20. Choledocholithiasis - Mindmap
  21. 21. Obstructive Jaundice- Diagnostic Algorithm
  22. 22. Choledocholithiasis Treatement Algorithm
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