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Hepatolithiasis
portal vein
Escherichia coli, Klebsiella pneumoniae, Pseudomonas
aeruginosa Proteus spp. anaerobes
RPC
extrahepatic intrahepatic duct focal stricture intrahepatic
biliary tree fibrosis
inflammatory cell infiltration left
hepatic duct left lateral segment
right hepatic
duct
calcium bilirubinate brown pigment stones hypertrophy of
the papilla of the sphincter of Oddi
hepatolithiasis
11-18 4-52
0.6-1.3 19
20-40 20
50-60 21
21,22
10
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23
1. Parasitic infection
24
Clonorchis sinensis, Opisthorchis species, Fasciola hepatica Ascaris lumbricoides RPC
20-4524-26
RPC ova
nidus 27,28
2. Bacterial infection
pigment stone RPC bacterial glucuronidase bilirubin glucuronide unconjugated bilirubin
calcium complex
glucuro-1,4-lactone -glucuronidase29
Hepatolithiasis
11
3. Bile stasis
recurrent cholangitis
(Charcots triad)
(Reynolds pentad)
15-30
atypical presentation
biliary
colic, acute pancreatitis, obstructive jaundice
hepatomegaly abnormal liver biochemistry19,21
bile duct perforation, bile peritonitis, secondary biliary cirrhosis, thrombophlebitis thrombosis
portal vein hepatic vein pulmonary thromboembolism
3,19,21
(liver abscess) (liver atrophy)
fibrous tissue dilated duct left lobe left
lateral segment secondary biliary cirrhosis
( 7) cholangiocarcinoma 21,22,30,31
cholestasis alkaline phosphatase
cholangiocarcinoma
atrophic left lobe
12
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cholangiocarcinoma 5-10
34-35 50 1030 recurrent cholangitis
hepatolithiasis
cholangiocarcinoma
Clonorchis sinensis
36,37
cholangiocarcinoma
leukocytosis,
abnormal liver chemistry serum alkaline phosphatase
bilirubin serum transaminase
ultrasound, CT scan,
MRI, MRCP, ERCP percutaneous transhepatic cholangiography (PTC)
ERCP PTC
hepatolithiasis
primary sclerosing cholangitis
1
RPC
ultrasound, computed tomography (CT) scan, contrast cholangiography magnetic resonance cholangiopancreatography (MRCP)
plain radiography of the abdomen
Hepatolithiasis
13
Hepatolithiasis
Ethnic group
Age
Gender
Presenting symptoms and signs
25-40
: 2-3 : 1
Fatigue, vague upper abdominal pain,
intermittent jaundice
Cholangitis less common
50-60
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radiopaque
Ultrasonography
RPC ultrasonography
posterior acoustic shadow
shadowing characteristics echogenicity
Lim 48 ultrasound
9838 echogenic with shadowing
77 without shadowing 13 mixed pattern 10
echogenic stones pneumobilia
prominent periportal echogenicity pericholangitis
periportal fibrous thickening 3039
ultrasound gallstones, liver abscesses, biloma
cholangiocarcinoma
ultrasound
extensive pneumobilia
CT scan
RPC CT scan
liver abscess, liver cirrhosis, biloma, bile duct
rupture with peritonitis, cholangiocarcinoma pancreatitis
Hepatolithiasis
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17
MRCP
heavily T2-weighted imaging sequences
fluid-filled structures
background MRCP contrast cholangiography thinslice, less heavily T2-weighted images
MRI thickening of the bile
duct wall, segmental atrophy, biloma, abscesses, cirrhotic changes
cholangiocarcinoma
Dilated duct
RPC
( diffusely dilated ducts with smooth
and gradual change of caliber of bile ducts) RPC
rapid tapering of the peripheral ducts
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19
Tsunoda Classification ( 2)
biliary cirrhosis 44-46
Endoscopic approach
ERCP
hepatolithiasis bile
duct strictures, peripheral stone impaction ductal angulation47,48
Tanaka49 hepatolithiasis 57 sphincterotomy common bile duct
intrahepatic duct 18
36 3
66-183
( 114 )
cholangitis 7 ( 2 ) liver abscess 3 ( 1 )
Percutaneous approach
percutaneous transhepatic drainage dilation
procedures catheters intrahepatic duct
18 Fr percutaneous transhepatic
cholangioscopy (PTCS)
20
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(11 18 ; p=0.007)
(20/34, 58.8% 33/86, 38.4%; p=0.042)
recurrent cholangitis cholangiocarcinoma
21
type III, IV
50 60
hepatolithiasis
Jan 614
427 4-10 380
PTCS 47 29.6 (105/355)
18.7 (80/427) secondary biliary cirrhosis
6.8 (29/427) cholangiocarcinoma 2.8 (12/427)
10.3 (44/427)
(
9.5) secondary biliary cirrhosis ( 2.1)
cholangiocarcinoma (p<0.01)
53,54
2
Tsunoda
(Tsunoda classification)55 119
.. 1969-1984
type I, II choledocholithotomy
choledochojejunostomy type III
type IV
bilioenteric anastomosis extended hepatico22
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choledochojejunostomy type IV
type IV
88
100 type I, 87 type II, 83 type III,
84 type IV
23
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1986;15:393-415.
49. Chijiiwa K, Yamashita H, Yoshida J, Kuroki S, Tanaka M. Current management
and long-term prognosis of hepatolithiasis. Arch Surg. 1995;130:194-7.
50. Suhocki PV. Long-term outcome of percutaneous transhepatic cholangioscopic
lithotomy for hepatolithiasis. Am J Gastroenterol. 2003;98:2589-90.
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