Topic 4b

Task 1

The 2 years ago, the patient underwent a

cholecystectomy for calculous cholecystitis. 6 months
after the operation, the patient began to experience
pain in the right hypochondrium and dark urine.
When entering the surgical clinic, the patient's blood
bilirubin is 120 mmol/l.

1. The preliminary diagnosis?

Postcholecystectomy syndrome - residual choleliathiasis.

2. What diagnostic method should be used to

determine the level of obstruction?

Chest x-ray ( differential diagnosis )

Ultrasound of the abdomen

Cholangioscopy by transpapillary or transhepatic access
Cholangiography – Antegrade cholangiography
Determining level of obstruction

Magnetic resonance cholangiopancreatography (MRCP)

Serology – ALT

Abdominal CT – calcified stones

3. What is supposed to cause PES in the patient?

Recurrent stones

The cystic duct is no more than 3mm. Small stone size

and large duct size, stones will move and obstruct.
The presence of residual cholelithiasis alters the bile
flow and the enterohepatic circulation

4. Tactics of examination and treatment.

Removal of the residual stones

ERCP

Endoscopic sphincterectomy

Antegrade percutaneous draining

TASK 2

Patient S., 68 years old, suffering from gallstone

disease, after a mistake in the diet suddenly had pains
in the upper abdomen, radiating to the back,
repeated vomiting of bile, hyperthermia up to 37.6,
chills. Diagnosed with acute cholecystitis. Performed
endoscopic cholecystectomy. A day after
cholecystectomy, yellowness of the skin appeared.

Objective: The state of moderate severity. The skin

and sclera are icteric. Pulse 90 per minute. HELL
120/80 mmHg The tongue is wet, coated. The
abdomen is slightly swollen, soft, painful in the
epigastrium. There are no peritoneal symptoms.
White blood cells 10.2 x 10 / l, total blood bilirubin 60
μmol / l. Urine diastasis 1024 units.

Questions:

1. Your diagnosis.

Postcholecystectomy syndrome.

2. Classification of the disease.

Immediate - 48 hours post-operative period.

Remote - after 48 hours pos-operative period.

According to etiology

1. Biliary
2. Non-biliary
3. The necessary examination methods to confirm the
diagnosis.

Abdominal ultrasound – White colour of stones and

hyper echogenecity
Chest x-ray ( differential diagnosis )

Ultrasound of the abdomen

Cholangioscopy by transpapillary or transhepatic access
Cholangiography – Antegrade cholangiography
Determining level of obstruction

Magnetic resonance cholangiopancreatography (MRCP)

Serology – ALT

Abdominal CT – calcified stones

4. Your tactic of the treatment

ERCP

Endoscopic sphincterectomy

Antegrade percutaneous draining

Use of temporary drainage using Pradery-Smith drain or

Kerr drain.
TASK 3

Patient N., 62 years old, was operated 30 days ago for

acute phlegmonous calculous cholecystitis, with a
history of jaundice. A cholecystectomy was
performed "from the fundus." A large number of
small stones were found in the gallbladder. Due to the
presence of severe infiltrate in the hepatoduodenal
ligament, a detailed revision of the common bile duct
was not performed. Cholangiography on the
operating table was not performed. The abdominal
cavity was sutured with a safety drainage that was
removed on the 6th day after the operation into the
subhepatic space. The patient's condition was
satisfactory, but on the 12th day after the operation
she opened an external bile fistula. There are no
symptoms of peritoneal irritation. Up to 600-700 ml
of bile was separated per day. Over time, the patient
developed weakness, diarrhea began to disturb, and
acholic stool was noted. Blood bilirubin 120.3 μm / l.

Questions:

1.What intraoperative study has not been performed

in a patient?

Intraoperative cholangiography for the determination of

the presence of residual stones in the cystic duct.

2.What could have caused the formation of an

external bile fistula?
The drainage inserted into the subhepatic space causes
the formation of the external fistula.

3) What is the treatment tactic?

Insertion of a rubber catheter into the fistulous tract

Antegrade drainage of the fistula - incising and draining

the abscess, in conjunction with the administration of
appropriate parenteral antibiotics.

Lithotripsy

Rabrom (glue) for occlusion of fistula

Subtotal cholecystectomy, leaving a remnant gallbladder

wall (5 mm in size) to perform the reconstruction of the
bile duct.

The insertion of a biliary stent across the papilla without

sphincterotomy is generally desirable to preserve the
biliary sphincter