Common bile duct stone

CHOLEDOCOLITHIASIS

1. Case PRESENTATION Department of SURGERY Sacred Heart Hospital PRESENTED BY DR. KALPANA SAH M.D. PGI 12/29/2016 1

2. General data A case of R.C.O 34 y.o , female married, filipina roman catholic nurse living in bolinwan carcar city , cebu 12/29/2016 2

3. CHIEF COMPLAINT RIGHT UPPER QUADRANT PAIN 12/29/2016 3

4. History of present illness 6 DAYS PTA Patient felt extreme pain on the epigastric area radaiting to the back (-) fever , (-) vomiting, Self medicated by ketorolac im , Temporary relief 5 DAYS PTA (+) persistent epigastric pain , Self medicated by ketorolac IM , pain tolerated ice tea colored urine Yellowish discoloration on her skin and sclera 4 DAYS PTA Sought consult to private physician Utz of whole abdomen was requested 12/29/2016 4

5. Ultrasound of whole abdomen (07/11/2016) GB intraluminal diameter: 2.8cm (N = < 4.0 cm) GB wall thickness : 0.3 cm ( N= < 0.4cm) Common duct : 1.1 cm ( N = < 0.6 cm) CBD is dilated with a 0.9 cm stone within Resultant mild ectasis of the intrahepatic biliary radicles Within the non ectatic GB are multiple mobile calculi ranging in size from 1.1 – 1.7 cm . The GB wall is not thickened. Liver is mildly enlarged Parenchymal echogenicity is mildly increased Impression: Choledocolithiasis with resultant mild ectasia of the intra hepatic biliary radicles Cholecystolithiasis Mild degree of fatty change with resultant mild increase in liver dimension 12/29/2016 5

6. History of present illness 3 DAYS PTA persistence of the condition Follow up with her physician for and was advised for surgical management ON THE DAY OF ADMISSION Pain persisted hence decided to be admitted 12/29/2016 6

7. PAST MEDICAL HISTORY Medical illness – none Medication – none Allergy – none Surgery – 2014 cesarean delivery CPD 2016 repeat cesarean delivery Hospitalization – 2014 and 2016 12/29/2016 7

8. PERSONAL / SOCIAL HISTORY Born and raised in carcar city Graduated bachelor of science in nursing on 2003 Practising nurse at district hospital carcar city Been to abudhabi for 2years Living together with her husband and 3 children No history of alcohol beverage drink , non smoker No any history of illicit drug use 12/29/2016 8

9. FAMILY HISTORY Paternal – hypertensive Maternal – none 12/29/2016 9

10. OBSTETRICAL / MENSTRUAL HISTORY Patient is G4P3013 G1 - 2004 - normal vaginal delivery G2 - 2011 - polyhydramnion result to death of 2 nd baby, G3 - 2014 - cesarean delivery , cephalopelvic dispropotion G4 - 2016 – cesarean delivery and ligation, repeat c / s Menarcheage at age 12 Regular menses , Dysmenorrhea , 3 to 4 days duration Uses natural family planning method Ligated at MAY 2016 12/29/2016 10

11. Physical exam General survey: Awake, Conscious, Coherent, Afebrile , Not in any Distress Vital signs: BP- 130/90 mmHg HR- 83 bpm RR- 21 cpm Temp- 36.6 C O 2 sat- 97% 12/29/2016 11

12. Physical exam Skin: warm, good turgor , , (-) rashes HEENT : Icteric sclera, Pink palpebral conjunctiva, (-) nasal discharges C/L: Equal chest expansion, clear breath sounds CVS: Distinct heart sound, (-) murmur ABDOMEN: Flabby, soft, normoactive bowel sound, soft, (+) epigastric tenderness, (+) murphy’s sign GUT: (-) Kidney Punch Sign EXTREMITY: strong peripheral pulse , good strength , Capillary Refill Time <2 sec, Strong peripheral pulse 12/29/2016 12

13. Impression Acute calculous cholecystitis with choledocolithaisis 12/29/2016 13

14. On day of admission Low fat diet was advised Iv fluid venoclysis plain LR at 30 gtts /min Labs were taken: CBC,Blood typing, Prothrombin time, Alkaline phosphate , U/A , NA , K , chest X ray PA-view Medication given cefoxitin ( monomel ) 1gm IVTT Patient was Reffered to IM for cp clearance 12/29/2016 14

15. Cbc (07/14/2016) CBC RESULT REF WBC 5.8 x 10 3 /mm 3 4.4-11.0 NEU 57.7% x 10 3 /mm 3 37-80 LYM 27.7% x 10 3 /mm 3 10-50 MON 8.5 % x 10 3 /mm 3 0-12 EOS 5.6 % x 10 3 /mm 3 0-7 BAS 0.5% x 10 3 /mm 3 0-2.5 RBC 4.9 x 10 9 /mm 3 4.5-5.10 HGB 12.4 g/dl 12.3-15.3 HCT 39.6 % 35.9-44.6 MCV 95 pg 80-96 MCHC 31.2 g/dl 27.5- 33.2 RDW 11.4 % 11.6- 14.8 PLT 331 x 10 3 /mm 3 150-450 MPV 7.6 um 3 6.0-11.0 12/29/2016 15

16. u/a (07/14/2016) URINALYSIS RESULT REFERENCE MACROSCOPIC EXAMINATION COLOR DARK YELLOW TRANSPARENCY HAZY PH 6.5 SPECIFIC GRAVITY 1.010 1.003 – 1.035 CHEMICAL PROPERTIES: PROTEIN (albumin) NEGATIVE NEGATIVE LEUKOCYTES NEGATIVE BLOOD / Hb 1+ NEGATIVE MICROSCOPIC PROPERTIES : WBC 3-6 / HPF 0-5/HPF RBC 0-3 / HPF 0-2/HPF BACTERIA ABUNDANT EPITHELIAL CELL FEW 12/29/2016 16

17. CLINICAL CHEMISTRY (07/14/2016) ANALYTE RESULT NORMAL RANGE RESULT NORMAL RANGE CREATININE 0.63 mg/ dL 0.51 – 0.95 55.7 umol /L 45.1 – 84.0 ALT (SGPT) 271 U/L , H <33 271 U/L <33 ALKALINE PHOSPHATE 208 U/L , H 35.0 - 104.0 208 U/L 35.0 - 104.0 SODIUM 145.6 mmol /L, H 136.0 – 145.0 145.6 mmol /L 136.0 – 145.0 POTASSIUM 3.4 mmol /L , L 3.5 – 5.1 3.4 mmol /L 3.5 – 5.1 12/29/2016 17

18. COURSE IN WARD Hospital Day 1 S O A P 07 /15 / 2016 Vital sign: BP – 130/80 mmhg PR – 81 bpm RR- 21cpm TEMP- 36.5 c (+) epigastric pain (-) vomiting, (-) nausea, (-) dizziness, good urine output, sleep well Awake , concious , coherent, not in respiratory distress Skin : warm , good turgor , (+) pale skin Heent : icteric sclerae , pinkish conjuctiva C/ L: equal chest expansion, clear breath sound Abd : (+) RUQ tenderness , Normoactive bowel sound Ext : strong pulse, CRT <2 sec. Patient is stable with stable vital sign Cefoxitin For schedule operation 12/29/2016 18

19. COURSE IN WARD Hospital Day 2 S O A P 07/16/ 2016 Vital sign: BP – 130/70 mmhg PR – 72 bpm RR- 20 cpm TEMP- 36.8 c (+) epigastric pain (-) vomiting, (-) nausea, (-) dizziness, good urine output, sleep well Awake , concious , coherent, not in respiratory distress Skin : warm , good turgor , (+) pale skin Heent : icteric sclerae , pinkish conjuctiva C/ L: equal chest expansion, clear breath sound Abd : (+) RUQ tenderness , Normoactive bowel sound Ext : strong pulse, CRT <2 sec. Patient is stable with stable vital sign Cefoxitin For schedule operation 12/29/2016 19

20. COURSE IN WARD Hospital Day 3 S O A P 07/17/ 2016 Vital sign: BP – 130/70 mmhg PR – 63 bpm RR- 22 cpm TEMP- 36.5 c (+) epigastric pain (-) vomiting, (-) nausea, (-) dizziness, good urine output, sleep well Awake , concious , coherent, not in respiratory distress Skin : warm , good turgor , (+) pale skin Heent : icteric sclerae , pinkish conjuctiva C/ L: equal chest expansion, clear breath sound Abd : (+) RUQ tenderness , Normoactive bowel sound Ext : strong pulse, CRT <2 sec. Patient is stable with stable vital sign NPO post midnight Pantoprazole 40mg IVTT Metoclopromide IVTT 12/29/2016 20

21. COURSE IN WARD Hospital Day 4 S O A P 07/18/ 2016 Vital sign: BP – 140/90 mmhg PR – 85 bpm RR- 20cpm TEMP- 36.5 c (+) epigastric pain (-) vomiting, (-) nausea, (-) dizziness, good urine output, sleep well Awake , concious , coherent, not in respiratory distress Skin : warm , good turgor , (+) pale skin Heent : icteric sclerae , pinkish conjuctiva C/ L: equal chest expansion, clear breath sound Abd : (+) RUQ tenderness , Normoactive bowel sound Ext : strong pulse, CRT <2 sec. Patient is stable with stable vital sign Patient for OR 12/29/2016 21

22. Surgery record PREOP DIAGNOSIS : obstructive jaundice 2 to choledocholithaisis with cholelithiasis Proposed operation : open cholecystectomy , IOC, choledochostomy , common bile duct exploration , T – tube cholangiogram OPERATION PROCEDURE : open cholecystectomy with IOC , CBDE, T-Tube cholangiogram POST OP DIAGNOSIS: obstructive jaundice 2 to choledocholithaisis with cholelithiasis 12/29/2016 22

23. IOC PICTURE 12/29/2016 23

24. SPECIMEN 12/29/2016 24

25. post op medication Tramadol 50mg IVTT PRN Ketorolac 30mg IVTT q6hr x 4doses Tramadol 50mg IVTT q6hr x4doses Pantoprazole 40mg IVTT q 24hr Cefoxitin 1gm IVTT q8hr 12/29/2016 25

26. COURSE IN WARD Hospital Day 5 S O A P 07/19/ 2016 Vital sign: BP – 120/70 mmhg PR – 83 bpm RR- 23 cpm TEMP- 36.5 c T tube drainage- 170 cc (+) pain at post op site (-) vomiting, (-) nausea, (-) dizziness, good urine output, sleep well Awake , concious , coherent, not in respiratory distress Skin : warm , good turgor , (+) pale skin Heent : icteric sclerae , pinkish conjuctiva C/ L: equal chest expansion, clear breath sound Abd : (+) RUQ tenderness , Normoactive bowel sound Ext : strong pulse, CRT <2 sec. Patient is stable with stable vital sign cbc Post op utz Tramadol 50mg IVTT q6hr x4doses Pantoprazole 40mg IVTT q 24hr 12/29/2016 26

27. Cbc (07/19/2016) CBC RESULT REF WBC 12.9 x 10 3 /mm 3 H 4.4-11.0 NEU 83.5 % x 10 3 /mm 3 H 37-80 LYM 9.1 % x 10 3 /mm 3 10-50 MON 5.3 % x 10 3 /mm 3 0-12 EOS 1.8 % x 10 3 /mm 3 0-7 BAS 0.3 % x 10 3 /mm 3 0-2.5 RBC 4.05 x 10 9 /mm 3 4.5-5.10 HGB 12.1 g/dl 12.3-15.3 HCT 38.2 % 35.9-44.6 MCV 94 pg 80-96 MCHC 31.6 g/dl L 27.5- 33.2 RDW 11.4 % 11.6- 14.8 PLT 290 x 10 3 /mm 3 150-450 MPV 7.8 um 3 6.0-11.0 12/29/2016 27

28. Post op ultrasound Liver –normal in size , shape and echotexture no mass detected no evidence of intrahepatic biliary duct dilatation . The intrahepatic vascular markings are within the limit is normal Gallbladder – no longer seeen due to previous cholecystectomy . The common bile duct is normal in caliber. Impression : No evidence of intrahepatic cholangiectasia Normal common bile duct No stone detected 12/29/2016 28

29. COURSE IN WARD Hospital Day 6 S O A P 07 /20 / 2016 Vital sign: BP – 120/70 mmhg PR – 75 bpm RR- 21 cpm TEMP- 36.5 c T tube drainage- 150 (+)Pain at post op site (-) vomiting, (-) nausea, (-) dizziness, good urine output, sleep well Awake , concious , coherent, not in respiratory distress Skin : warm , good turgor , (+) pale skin Heent : icteric sclerae , pinkish conjuctiva C/ L: equal chest expansion, clear breath sound Abd : (+) RUQ tenderness , Normoactive bowel sound Ext : strong pulse, CRT <2 sec. Patient is stable with stable vital sign Tramadol 50mg IVTT q6hr x4doses Pantoprazole 40mg IVTT q 24hr 12/29/2016 29

30. COURSE IN WARD Hospital Day 7 S O A P 07 /21/ 2016 Vital sign: BP – 130/90 mmhg PR – 79 bpm RR- 22 cpm TEMP- 36.5 c (+) mild pain on post op site (-) vomiting, (-) nausea, (-) dizziness, good urine output, sleep well Awake , concious , coherent, not in respiratory distress Skin : warm , good turgor Heent : Anicteric sclerae , pinkish conjuctiva C/ L: equal chest expansion, clear breath sound Abd : (- ) RUQ tenderness , Normoactive bowel sound Ext : strong pulse, CRT <2 sec. Patient is stable with stable vital sign Ok for discharge Take home medication - Cefuroxime 500mg BID - Celecoxib 200mg BID 12/29/2016 30

31. Discussion CHOLEDOCOLITHIASIS 12/29/2016 31

32. CHOLEDOCHOLITHIASIS Common bile duct stones Small or large = single or multiple, Found in 6% to 12% of patients with stones in the GB The incidence increases with age. 12/29/2016 32

33. CHOLEDOCHOLITHIASIS Primary CBD Stones  that form in the bile ducts. Usually brown pigment type  associated w/ biliary stasis & infection more commonly seen in Asian populations. The causes of biliary stasis that lead to the development of primary stones include biliary stricture, papillary stenosis , tumors, or other (secondary) stones. Secondary CBD stones: formed within the gallbladder  migrate down the cystic duct to the common bile duct. usually cholesterol stones 12/29/2016 33

34. CHOLEDOCHOLITHIASIS CLINICAL MANIFESTATIONS SILENT , often discovered incidentally. may cause obstruction, complete or incomplete, OR may manifest with cholangitis or gallstone pancreatitis. The PAIN of CBD Stone= also biliary colic (similar to cystic duct stone) Jaundice , Nausea and vomiting are common. 12/29/2016 34

35. CHOLEDOCHOLITHIASIS PHYSICAL EXAMINATION may be normal, but mild epigastric or RUQ tenderness as well as mild icterus are common. The symptoms – intermittent; pain and transient jaundice (temporarily impacts the ampulla but subsequently moves away, acting as a ball valve ) CBD stone  pass through the ampulla spontaneously  resolution OF Sx . become completely impacted  severe progressive jaundice. 12/29/2016 35

36. DIAGNOSTIC STUDIES ROUTINE Blood Tests : 1. CBC Increased WBC : raise suspicion of CHOLECYSTITIS. 2. LIVER FUNCTION TEST elevation of bilirubin , alkaline phosphatase , and aminotransferase , CHOLANGITIS should be suspected. elevation of conjugated bilirubin & and a rise in alkaline phosphatase  CHOLESTASIS. Serum aminotransferases may be normal or mildly elevated. In patients with biliary colic or chronic cholecystitis blood tests will typically be normal. 12/29/2016 36

37. Initial investigations 2. Liver Function Test (LFT) Completely normal: NPV > 97% Abnormal: PPV 15% Bilirubin is the strongest predictor for CBD stones ; specificity varies according to level Bilirubin ≥ 30 µmol/L: specificity 60% Bilirubin ≥ 68 µmol/L: specificity 75% Mean bilirubin in CBD stones: 25.5 – 32.3 µmol/L 12/29/2016 37

38. DIAGNOSTIC STUDIES 1. ULTRASONOGRAPHY= first test documenting stones in the GB (if still present) determining the size of the common bile duct A dilated common bile duct (>8 mm in diameter) + jaundice, and biliary  common bile duct stones. 12/29/2016 38

39. DIAGNOSTIC STUDIES ULTRASONOGRAPHY Advantages: Initial investigation of GBD Noninvasive, painless, No radiation exposure can be performed on critically ill patients. Adjacent organs can frequently be examined at the same time. Disadvantages Operator dependent Not satisfactory for Obese patients, patients with ascites & distended bowel 12/29/2016 39

40. DIAGNOSTIC STUDIES ULTRASONOGRAPHY GALLSTONE sensitivity and specificity of >90%) dense, acoustic shadow Move with changes in position POLYPS may be calcified  reflect shadows do not move with change in posture. Acoustic shadows from gall stones. 12/29/2016 40

41. Diagnosis studies 2. Magnetic resonance cholangiography (MRC) ( pcs guidelines 2014) provides excellent anatomic detail sensitivity and specificity of 95% and 89% detecting choledocholithiasis >5 mm in diameter 3. Endoscopic cholangiography GOLD STANDARD FOR DIAGNOSING COMMON BILE DUCT STONES . distinct advantage : THERAPEUTIC OPTION at the time of diagnosis. 12/29/2016 41

42. DIAGNOSTIC STUDIES 4. ORAL CHOLECYSTOGRAPHY OLD DAYS : diagnostic procedure of choice for gallstones, Replaced by ultrasonography . oral administration of a radiopaque compound absorbed, excreted by the liver, and passed into the GB. Stones are noted on a film as FILLING DEFECTS in a visualized, opacified gallbladder. Oral cholecystography is of no value in: patients with intestinal malabsorption vomiting, obstructive jaundice, and hepatic failure. STONE FILLING DEFECTS 12/29/2016 42

43. DIAGNOSTIC STUDIES 5. BILIARY RADIONUCLIDE SCANNING (HIDA SCAN) noninvasive evaluation of the liver, gallbladder, bile ducts, and duodenum with both anatomic and functional information dimethyl iminodiacetic acid (HIDA) are injected intravenously, cleared by the Kupffer cells in the liver, and excreted in the bile. Uptake by the liver : 10 minutes GB, bile ducts & the duodenum : visualized within 60 minutes (fasting) 12/29/2016 43

44. Diagnostic studies PRIMARY USE : diagnosis of ACUTE CHOLECYSTITIS, appears as a nonvisualized gallbladder AFTER 4 HOURS with prompt filling of the common bile duct and duodenum Evidence of cystic duct obstruction ? acute cholecystitis . Biliary leaks as a complication of surgery can be identified. 12/29/2016 44

45. Normal cholescintigrams normal gallbladder filling within 45 minutes. No filling of the gallbladder  cystic duct obstruction. 12/29/2016 45

46. DIAGNOSTIC STUDIES 6. COMPUTED TOMOGRAPHY Inferior to UTZ in diagnosing gallstones. TEST OF CHOICE in evaluating suspected MALIGNANCY of the gallbladder, the extrahepatic biliary system, head of the pancreas. Spiral CT scanning provides additional staging information, including vascular involvement in patients with periampullary tumors CT scan shows pearl gallstones and thickening of the gallbladder wall. 12/29/2016 46

47. DIAGNOSTIC STUDIES 7. PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY (PTC) Intrahepatic bile ducts are accessed percutaneously with a small needle under fluoroscopic guidance. Once the position in a bile duct has been confirmed, a guidewire is passed, and subsequently, a catheter is passed over the wire Through the catheter, a cholangiogram can be performed and therapeutic interventions done, such as biliary drain insertions and stent placements. 12/29/2016 47

48. DIAGNOSTIC STUDIES PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY (PTC) little role in the uncomplicated gallstone disease particularly useful in patients with BILE DUCT STRICTURES AND TUMORS  defines the anatomy of the biliary tree proximal to the affected segment. potential risks bleeding, cholangitis , bile leak 12/29/2016 48

49. DIAGNOSTIC STUDIES BILE DUCT STRICTURES PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY (PTC) 12/29/2016 49

50. DIAGNOSTIC STUDIES 8. MAGNETIC RESONANCE IMAGING MRI provides ANATOMIC DETAILS of the liver, gallbladder, and pancreas similar to those obtained from CT. can generate high-resolution anatomic images sensitivity and specificity of 95% and 89% respectively, at detecting choledocholithiasis . MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY (MRCP) offers a single noninvasive test for the diagnosis of biliary tract and pancreatic disease course of the extrahepatic bile ducts ( arrow) and pancreatic duct ( arrowheads). 12/29/2016 50

51. DIAGNOSTIC STUDIES 9. ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP) Using a side-viewing endoscope, the common bile duct can be cannulated and a cholangiogram performed using fluoroscopy requires intravenous (IV) sedation for the patient. 12/29/2016 51

52. ERCP The ADVANTAGES OF ERC include direct visualization of the ampullary region direct access to the distal common bile duct, with the possibility of therapeutic intervention. ERC is the diagnostic and often therapeutic procedure of choice. Once the endoscopic cholangiogram has shown ductal stones, sphincterotomy and stone extraction can be performed, and the common bile duct cleared of stones 12/29/2016 52

53. DIAGNOSTIC STUDIES ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP) SUCCESS RATE of common bile duct cannulation and cholangiography >90%. COMPLICATIONS of diagnostic ERC pancreatitis and cholangitis (5%) considered safe THERAPEUTIC APPLICATIONS biliary stone lithotripsy & extraction in high-risk surgical patients 12/29/2016 53

54. ENDOSCOPIC RETROGRADE CHOLANGIOGRAPHY. A schematic picture showing the side-viewing endoscope in the DUODENUM and a catheter in the common bile duct. B. An endoscopic cholangiography showing stones in the COMMON BILE DUCT. The catheter has been placed in the ampulla of Vater ( arrow). Note the duodenal shadow indicated with arrowheads. 12/29/2016 54

55. DIAGNOSTIC STUDIES 10. ENDOSCOPIC ULTRASOUND special endoscope with an ultrasound transducer at its tip. operator dependent, but offer noninvasive imaging of the bile ducts and adjacent structures. Of particular value in the EVALUATION OF TUMORS & their RESECTABILITY. The ultrasound endoscope has a BIOPSY CHANNEL needle biopsies of a tumor under ultrasonic guidance Can identify bile duct stones less sensitive than ERC less invasive as cannulation of the sphincter of Oddi is not necessary for diagnosis of choledocholithiasis 12/29/2016 55

56. ENDOSCOPIC ULTRASOUND 12/29/2016 56

57. DIAGNOSTIC STUDIES ENDOSCOPIC ULTRASOUND EUS demonstrating a small stone (arrowed) within the common bile duct that was not observed on MRCP 12/29/2016 57

58. Treatment and management 12/29/2016 58

59. 12/29/2016 59

60. treatment 1. Cholecystostomy 2. Cholecystectomy 3. Laparoscopic Cholecystectomy 4. Open Cholecystectomy 5. Choledochoduodenostomy ( pcs guidelines ,2014) Least recurrence 12/29/2016 60

61. Treatment 1. Cholecystostomy Decompresses and drains the distended inflamed, hydropic , or purulent gallbladder. applicable if the patient is not fit to tolerate an abdominal operation. Ultrasound-guided percutaneous drainage with a pigtail catheter is the procedure of choice. 12/29/2016 61

62. ERCP ERCP 24 TO 48 HOURS 12/29/2016 62

63. CHOLEDOCHOLITHIASIS treatment Symptomatic gallstones + suspected common bile duct stones, either : preoperative endoscopic cholangiography or intraoperative cholangiogram If an ENDOSCOPIC CHOLANGIOGRAM  reveals stones sphincterotomy and ductal clearance of the stones is appropriate, followed by a laparoscopic cholecystectomy . 12/29/2016 63

64. Treatment An INTRAOPERATIVE CHOLANGIOGRAM (IOC) at the time of cholecystectomy will also document the presence or absence of bile duct stones Open common bile duct exploration option if the endoscopic method is not feasible AMPULLARY STONES  CBD >2cm, CBDE/Endoscopy are difficult . choledochoduodenostomy OR a Roux-en-Y choledochojejunostomy 12/29/2016 64

65. Treatment RETAINED STONES ERCP - confirmed retained CBD stones, treat with ERCP. stones deliberately left in place at the time of surgery retrieved either endoscopically or via the T-tube tract once it has matured (2–4 weeks). RECURRENT STONES diagnosed months or years later, multiple& large endoscopic sphincterotomy  stone retrieval Retained or recurrent stones following cholecystectomy are best treated ENDOSCOPICALLY 12/29/2016 65

66. Common Bile Duct Drainage Procedures Rarely, when the stones cannot be cleared and/or when the duct is very dilated (>1.5 cm in diameter), a choledochal drainage procedure is performed Choledochoduodenostomy is performed by mobilizing the second part of the duodenum (a Kocher maneuver) and anastomosing it side to side with the common bile duct. 12/29/2016 66

67. Common Bile Duct Drainage Procedures A choledochojejunostomy is done by bringing up a 45-cm Roux-en-Y limb of jejunum and anastomosing it end to side to the common bile duct. Choledochojejunostomy or, more often, a hepaticojejunostomy , also can be used to repair common bile duct strictures or as a palliative procedure for malignant obstruction in the periampullary region. If the common bile duct has been transected or injured, it can be managed by an end-to-end choledochojejunostomy 12/29/2016 67

68. Transduodenal Sphincterotomy Endoscopic sphincterotomy has replaced open transduodenal sphincterotomy . Open procedure - stones are impacted, recurrent, or multiple, the transduodenal approach may be feasible. 12/29/2016 68

69. Complication Two main complications of choledochal stones: Cholangitis Gallstone pancreatitis. 12/29/2016 69

70. histopath FINAL DIAGNOSIS – CHOLEDOCOLITHIASIS Gallbladder measure 6.5 x 2.0 x 1.5 cm Opening reveals several stones measuring from 1.0 to 1.5cm in greater dimension Mucosa is green brown and fibrotic Wall measures 0.3 cm thick Microscopic examination – lympho plasmacytic infiltration of the edematous and partly fibrotic gallbladder wall and mucosa Gallbladder mucosa is mostly effaced with area The walls show few glands lined by columnar epithelium cells with basal nuclei No atypia is seen. 12/29/2016 70

71. End of slide Thank you for listening 12/29/2016 71

72. Treatment cholangitis ( pcs guidelines 2014) Cholangitis Ciprofloxacin 200mgs IV BID or Ceftazidime 1gm IV BID + Ampicillin 500mgs IV QID + Metronidazole 500mgs IV TID (Level 1B, Category B) Alternative Piperacillin + an Aminoglycoside + Metronidazole or Piperacillin-Tazobactam or Ampicillin-Sulbactam or Ticarcillin Severe cholangitis Non-operative biliary drainage (endoscopic). If endoscopic drainage is not available or is not successful, percutaneous transhepatic biliary drainage (PTBD) or surgical decompression are the recommended alternatives. 12/29/2016 72