CHOLEDOCHOLITHIASIS

 stones in common bile duct

 
Signs and symptoms
1. 50% asymptomatic
2. tenderness in RUQ or epigastrium biliary pain with intermittent chills, fever or
fluctuating jaundice
3. episodic cholangitis
4. spectrum from healthy to icterus, toxicity, high fever and chills
 
Diagnostic investigations 
1. increased bilirubin (<10), ALP
2. leukocytosis often > 20 x 109/L
3. U/S - duct dilatation, does not detect CBD stones
4. ERCP (if no previous cholecystectomy) otherwise PTC appropriate
 
Treatment 
1. antibiotics, NG tube, IV hydration
2. if no improvement in 2-4 days then ERCP/PTC+sphincterotomy or surgery with CBD
exploration and laparoscopic cholecystectomy
 
 
DIAGNOSTIC EVALUATION OF BILIARY TREE
 
U/S is diagnostic procedure of choice
 
 Oral cholecystography
1. Opaque drug taken night before, look for filling defect (stones)
2. failure of gallbladder to opacify indicative of complete obstruction by stone or unable
to concentrate because of inflammation
HIDA scan
1. radioisotope technetium excreted in high concentrations  in bile
2. highly suggestive of acute cholecystitis when gallbladder not visualized due to cystic
duct obstruction 4 hours after injection reliable when bilirubin > 20
PTC
1. injection of contrast via needle passed through hepatic parenchyma
2. useful for proximal bile duct lesions or when ERCP fails
3. antibiotic premedication always, contraindicated with cholangitis
ERCP -(Endoscopic Retrograde Cholangiopancreatography)
1. opacification of bile and pancreatic ducts possible
2. preferred method to demonstrate CBD stones and periampullary region