CHOLEDOCHOLITHIASIS.pptx

A short presentation on choledocholithiasis

1. choledocholithiasis

2. Introduction  Stones Inside The Common Bile Duct And Billiary Tree Choledocholithiasis occurs as a result of either the primary formation of stones in the common bile duct (CBD) or the passage of gallstones from the gallbladder through the cystic duct into the CBD. Majority of the bile duct stones are cholesterol stones formed in the gallbladder which then migrates into the exrahepaticbiliary tree through the cystic duct [secondary ]

3. CLASSIFICATION PRIMARY:-  Formed in CBD and biliary tree itself Rare Brown pigment or mixed type stones Multiple, often sludge like, extends into hepatic duct.

4. Causes of Primary Choledocholithiasis:- 1. Hepatobiliary parasitism or chronic, recurrent cholangitis  2. Congenital anomalies of the bile ducts  3. Dilated or sclerosed or structured ducts  4. MD3 gene defect leading to impaired biliary phospholipids secretion

5. Secondary Choledocholithiasis :- They are from gallbladder (gall stones), pass through Cystic Duct to CBD. Here CBD & biliary tree are otherwise normal.  Common  Black pigment stones/cholesterol stones (75% are cholesterol & 15% are pigment stones) . Secondary stones are better and easier to manage than primary stones . 15% of gall stones leades to secondary choledocholithiasis. Commonly gall stones get impacted in supraduodenal portion of the CBD.

6. Clinical Manifestations 50% asymptomatic Symptoms usually do not occur unless the stone blocks the common bile duct Symptoms and signs usually present as RUQ abdominal pain  Jaundice Pruritis  Fever  Dark colored urine  Clay colored stools  Nausea and or Vomiting

7. Risk factors People with a history of gallstones or gallbladder disease  are at risk for bile duct stones. 0besity Low-fiber, High-calorie, High-fat Diet Pregnancy Prolonged Fasting Rapid Weight Loss Lack Of Physical Activity Risk factors you cannot change include: Age : Older Adults Typically Have A Higher Risk For Gallstones Gender : Women Are More Likely To Have Gallstones Family History: Genetics May Play A Role

8. COMPLICATIONS Liver Dysfunction & Biliary atresia White Bile formation & liver failure Suppurative Cholangitis Obstructive jaundice Liver abscess Septicemia Pancreatitis.

9. Diagnosis   LABORATORY: - CBC- TC WBC  Platelet Count Liver function tests:-  S. Bilirubin S. ALP & GGT S. ALT & AST S. Protein Prothombin  Time S. Amylase S. Lipase Urine

10.  RADIOLOGICAL  USG Abdomen:   It may show Gallstones,  Dilated CBD>8mm with symptoms ,  Dilated CBD even without biliary colic in presence of gall stones highly suggestive of biliary obstruction . Sensitivity for gall stones only 65%

11. MRCP (Magnetic Resonance Cholangiopancreatography):-  Non contrast non invasive imaging method better than ERCP in Diagnostic tool in biliary & pancreatic diseases . It delineates biliary tree anatomy & pathology clearly . But not therapeutic . Highly(>90%) sensitive & almost 100% specific. .

12. CT Scan:-  It shows stones , location, ductal stricture or block , ductal dilatation, intra hepatic biliary changes & stones.  Helical CT cholangiography is also useful but bilirubin level should be normal which is the limitation. EUS(Endoscopic Ultrasonography) :- Useful & accurate but is invasive. PTC(Percutaneous Transhepatic Cholangiography) :- done only when indicated like in case of previous Gastrectomy , failed ERCP. Not routinely done. ERCP(Endoscopic Retrograde  Cholangio  Pancreatography) :- now a days mostly Therapeutic use.

13. TREATMENT  Non-surgical  • ERCP  • Percutaneous extraction  • Extracorporeal shock wave lithotripsy

14. Surgical :- Open choledochotomy  Transcystic exploration  Drainage procedures  Transduodenal sphincteroplasty  Choledocho -duodenostomy  Choledocho -jejunostomy  Biliary Endoscopic Sphincterotomy Cholecystectomy

15. T- TUBE CHOLANGIOGRAPHY After choledochotomy, a T-tube (Kehr's) is then placed in the CBD and kept for 14 days. After 14 days a postoperative T-tube cholangiogram is done to see for free flow of dye into the duodenum, so that T-tube can be removed.  If T-tube cholangiogram shows persistent stone, it Can be extracted after 6 weeks, through a basket ( Dormia ) or catheter (Fogarty) through the track or through a choledochoscope .