Understanding Choledocholithiasis: Types & Treatment
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Attiba RizwanUnderstanding Choledocholithiasis: Types & Treatment
Uploaded by
Attiba RizwanCholedocholithiasis
Presented by:
Attiba Rizwan
Shifa Fatima
Learning objectives
Anatomy
Introduction to choledocholithiasis types and causes
Case presentation
History and examination
Investigations
Treatment
CHOLEDOCHOLITHIASIS
Presence of one or more than one
gallstone/stone in cystic duct or common bile
duct
TYPES:
Primary stones : Stones that are formed
in ducts due to infection/infestation
• Brown pigment stones
Secondary stones : That migrate from
gallbladder
• Cholesterol stones
How stones are formed??
Cholesterol stones are caused by bile that contains:
• too much cholesterol
• too much bilirubin
• not enough bile salts
• may also occur if the gallbladder doesn’t empty completely or often.
The cause of pigment stones is not known. They seem to occur in people
who have:
• cirrhosis of the liver
• biliary tract infections
• hereditary blood disorders in which the liver makes too much bilirubin
People at risk
History of gallstones
low-fiber, high-calorie, high-fat diet
prolonged fasting
• rapid weight loss
• F atty
• F orty
• F emales
• F amily history
Scenario
. A 45 years old female housewife presented in OPD with history of right
hypochondrium pain, fever and intermittent jaundice for last month. She was
previously diagnosed as a case of cholelithiasis. On examination there is
jaundice with impalpable gall bladder.
a. What is your diagnosis?
b. What investigations will you perform?
c. How will you manage the patient?
Sign and symptoms
Symptoms:-
Pain (right upper quadrant)
Jaundice
Fever (inflammation in biliary system)
(Charcot's triad)
Sign:-
Epigastrium and right hypochondrium
tenderness
COURVOISIER’S LAWS:
• In CBD obstruction due to a stone, distension of
the gallbladder seldom occurs; the organ usually is
already shrivelled.
• In obstruction from other causes, distension is
common, by comparison. However, if there is no
disease in the gallbladder and the obstruction is
due to a cancer of the ampulla, pancreas or bile
duct, then the gallbladder may well be distended.
Investigations
History
Clinical examination
• Radiological investigation:
Transabdominal ultra sound
MRCP
• Laboratory investigations
LFTs, Bilirubin
Liver Biopsy ( if ducts are not dilated)
COMPLICATIONS
• A gallstone that blocks your common bile duct will cause bile to back up
behind the blockage. This can affect all of your ducts and organs
connected to it, including your gallbladder, pancreas and liver. It causes
inflammation, breeds infection and can lead to long-term tissue damage.
• INFECTION – Due to stasis of bile
• CHOLANGITIS – Backed-up bile causes bile duct to swell, which
further slows bile flow
• PANCREATITIS – Bile ducts share same exit channel into intestines as
your pancreas. Gallstones that block this common channel can also block
secretions from your pancreas. These secretions, w/ potent enzymes, will
back up into pancreas and cause severe inflammation and organ damage.
• Gallstones obstructing your bile ducts is the most common cause of non-
alcohol-related pancreatitis.
INVESTIGATIONS
• LAB INVESTIGATIONS
• BILIRUBIN
• LFTS
• PANCREATIC ENZYMES
• CBC
• RADIOLOGICAL INVESTIGATIONS
• ERCP: anatomy, stones and biliary strictures
• Radiological investigation of the biliary tree
• TUS: transabdominal ultrasound
• MRCP
• CT scan: anatomy, liver, gallbladder and.
pancreatic cancer
• PTC: anatomy and biliary strictures
• EUS: anatomy, stones
Transabdominal USG
MRCP
TREATMENT
Rehydration
Attention to clotting
Exclusion of diabetes
Give broad-spectrum antibiotics
• Removal of stone
Definitive treatment:-
ERCP – minimally invasive
Choledochotomy
Provide supportive therapy for patients with acute
symptoms.
Provide initial supportive therapy of acute biliary disease,
e.g., analgesics, spasmolytics, antiemetics.
NPO for patients with acute pain
Identify and treat any complications (e.g., acute
pancreatitis, cholangitis, cholecystitis).
Provide definitive management of choledocholithiasis:
Removal of CBD stone, e.g., via ERCP
• Elective cholecystectomy to prevent recurrence
Stone extraction
fragmenting stones (lithotripsy)
surgery to remove the gallbladder and stones (cholecystectomy)
surgery that makes a cut into the common bile duct to remove
stones or help them pass (sphincterotomy)
biliary stenting
• The most common treatment for gallstones in the bile duct is
biliary endoscopic sphincterotomy (BES). During a BES
procedure, a balloon- or basket-type device is inserted into
the bile duct and used to extract the stone or stones. About
85 percent of bile duct stones can be removed with BES.
