Choledocholithiasis

Done By: Abdullah Zuhair Alkhars Batch: 217 Contact Me At: Abdllhzk@gmail.com
Definition:
It Refers To The Presence Of Stones In The Common Bile Duct.
Classification:
(1) Primary Choledocholithiasis (5% Of All Cases):
This Commonly Is Associated With TPN & Cystic Fibrosis > Intra-Ductal Bile Stasis In The CBD > Bile
Components Dissociation With Consequent Cholesterol Particles Precipitation As It Is Insoluble By
Itself > Intra-Ductal Pigmented Stones Formation "Choledocholithiasis".
(2) Secondary Choledocholithiasis (95% Of All Cases):
This Is When Stones Form Initially In Gallbladder, But Then Get Pumped Into CBD Postprandially.
Pathogenesis:
CBD Stones > The Bile Being Made In Liver & The Bile Stored In Gallbladder Can No Longer Reach
The Duodenum When Pumped > This Causes 2 Consequences (i) Bile Accumulates In The Hepatic
Canaliculi, Leading To ↑ Pressure With Consequent Bile Infiltration Into Plasma & Hepatic Injury
(ii) Pancreatic Juice & Bile Will Respectively Accumulate & Reflux Into Pancreatic Duct, Resulting
In Autodigestion And Finally Acute Pancreatitis.
Clinical Manifestations:
(1) Fever & Malaise & Anorexia.
(2) Postprandial RUQ Pain > 6H With N/V & (-) Murphy Sign.
(3) Obstructive Jaundice (Yellowish Discoloration & Pruritis & Dark Urine & Pale Stool ).
Complications:
(i) Acute Pancreatitis:
Choledocholithiasis > The Bile Being Made In Liver & The Bile Stored In Gallbladder Can No Longer
Reach Duodenum When Pumped > Pancreatic Juice & Bile Will Respectively Accumulate & Reflux
Into Pancreatic Duct, Resulting In Autodigestion And Finally Acute Pancreatitis.
(ii) Ascending Cholangitis:
Choledocholithiasis > The Bile Being Made In Liver & The Bile Stored In Gallbladder Can No Longer
Reach Duodenum When Pumped > If Bile Does No Longer Get Pumped Into Duodenum, Biliary Tree
Won't Be Washed Out From Bowel Ascending Microbes, Allowing E. Coli, Klebsiella, Enterobacter,
Enterococcus To Reach The CBD & Establish An Infection.
(iii) Biliary Cirrhosis:
Choledocholithiasis > The Bile Being Made In Liver & The Bile Stored In Gallbladder Can No Longer
Reach Duodenum When Pumped > Bile Accumulates In The Hepatic Canaliculi, Leading To ↑
Pressure With Consequent Bile Infiltration Into Plasma & Hepatic Injury.
DDx & Diagnosis:
The Differential Diagnosis Of RUQ Pain Associated With Jaundice & CBD Dilation Include:
(1) Biliary Strictures. (2) Head Of Pancreas Carcinoma. (3) Choledocholithiasis.
(4) Porta Hepatis Lymphadenopathy (Extrinsic Compression) . (5) Cholangiocarcinoma.
(6) Sphincter Of Oddi Dysfunction. (7) Urolithiasis/UTI. (8) Irritable Bowel Syndrome.
(9) Acute Hepatitis. (10) Early Appendicitis. (11) Peptic Ulcer. (12) Acute Pancreatitis.
Meanwhile, Choledocholithiasis Is Diagnosed As Follows:
(I) Imaging Techniques (To Establish Diagnosis):
(i) RUQ Ultrasound (Best Initial Test But Is Not Sensitive Enough To Rule Out Dx):
It Shows "Dilated CBD & Stones In CBD/Gallbladder & Dilated Intrahepatic Biliary Tree ".
(iiI) MRCP (Most Accurate Test "Used With ↓ CBD Stone Suspicion"):
It Shows "Dilated CBD & Smooth-Walled Intraluminal Filling Defect Within The CBD".
(ii) ERCP (Most Accurate Test & Therapeutic "Used With ↑ CBD Stone Suspicion"):
It Shows "Dilated CBD & Smooth-Walled Intraluminal Filling Defect Within The CBD ".
(II) Laboratory Tests (To Support Dx & Rule Out Complications):
(i) Complete Blood Count:
There'll Be Normal WBCs Counts (Signifying No Infection "Cholecystitis/Cholangitis").
(ii) Liver Function Tests:
There'll Be ↑ ALT & AST (CBD Obstruction > Released By Damaged Hepatic Cells).
There'll Be ↑ Direct Bilirubin & GGT & ALP (CBD Obstruction > Released By Damaged Hepatic Cells).
(iii) Pancreatic Enzymes:
There'll Be ↑ Amylase & Lipase (CBD Obstruction > Released By Damaged Pancreatic Cells).

Treatment:
If Patient Is Presenting With Acute Sx > NPO & Iv Fluids & Analgesia/Antiemetic/Spasmolytic.
Definitive Treatment Is By > ERCP For Sphincterotomy & Stone Extraction With Stent Placement.
Offer Elective Cholecystectomy To Prevent Recurrence .

Notes:
(1) The Symptoms Depend On The Degree & Duration Of The Obstruction And Whether An Infection
Has Developed Or Not; Patients Might Be Asymptomatic For Years But The Onset Of Sx Can Signal
The Development Of Life-Threatening Complications Like Acute Pancreatitis & Acute Cholangitis.
(2) Surgery Is Curative & Recommended But Patients Might Report Post-Cholecystectomy Syndrome
Where RUQ Pain & N/V & Early Satiety & Flatulent Dyspepsia Are Experienced. Those Features May
Be Due To Biliary Tree Retained Stones Whose Extractions Were Missed During Operation Or Biliary
Tree Stricture 2° To Intra-Operative Injuries With Consequent Intra-Ductal Stasis & Microlithiasis Or
Sphincter Of Oddi Dysfunction Or Concurrent Extra-Biliary Disorder. Investigate/Treat As Needed.
(3) Alternative To The Surgical Mx Of The Gallstones Disorder, The Drug Ursodeoxycholic Acid Can
Be Used To Dissolve Small Cholesterol Stones "< 1 Cm". It's A Bile Salt Itself & ↓ Hepatic Secretion
Of Cholesterol, But Have Slow Action, Side-Effect Like Severe Diarrhea, And High Recurrence Rate.
It Is Thus Only Used In Some Occasions Like If Patient Is Unfit For Surgery, For Those With Primary
Sclerosing Cholangitis, For Pregnant Women With Cholelithiasis, Or Following Bariatric Surgeries.