Etiology / PathophysiologyEtiology / Pathophysiology Stones in the bile ductsStones in the bile ducts

- Gallstones originate in the gallbladder and - Gallstones originate in the gallbladder and are passed into the common bile duct and/or are passed into the common bile duct and/or hepatic ductshepatic ducts- In rare instrances, primary bile duct stones - In rare instrances, primary bile duct stones may form in a patient who has had a prior may form in a patient who has had a prior cholecystectomycholecystectomy

4% of patients with cholelithiasis are found 4% of patients with cholelithiasis are found to have choledocholithiasis, without to have choledocholithiasis, without symptoms of common bile duct obstructionsymptoms of common bile duct obstruction

Differential DxDifferential Dx CholecystitisCholecystitis Peptic ulcer diseasePeptic ulcer disease HepatitisHepatitis Liver abscessLiver abscess GastritisGastritis PancreatitisPancreatitis Carcinoma of the liver or bile ductsCarcinoma of the liver or bile ducts Carcinoma of the gallbladderCarcinoma of the gallbladder CholangitisCholangitis Biliary obstructionBiliary obstruction Right lower lobe pulmonary disease (e.g., PE, Right lower lobe pulmonary disease (e.g., PE,

pneumonia)pneumonia) Myocardial ischemiaMyocardial ischemia

Presentation / Signs & SymptomsPresentation / Signs & Symptoms Episode RUQ / epigastric painEpisode RUQ / epigastric pain Nausea/vomitingNausea/vomiting Internittent jaundiceInternittent jaundice Dark urine ( bilirubinuria )Dark urine ( bilirubinuria ) Acholic stoolsAcholic stools Gallbladder is most often non-Gallbladder is most often non-

palpable as opposed to a malignant palpable as opposed to a malignant obstruction of the bile ducts (e.g., obstruction of the bile ducts (e.g., pancreatic cancer, distal bile duct pancreatic cancer, distal bile duct cancer, ampullary cancer)cancer, ampullary cancer)

May be asymptomaticMay be asymptomatic

Diagnostic EvaluationDiagnostic Evaluation

Elevated LFTs (especially bilirubin and Elevated LFTs (especially bilirubin and alkaline phosphatase) suggest alkaline phosphatase) suggest obstructive jaundiceobstructive jaundice

Ultrasound may reveal common bile and Ultrasound may reveal common bile and heparic duct dilatation rarely, a common heparic duct dilatation rarely, a common bile duct stone may be identifiedbile duct stone may be identified

Endoscopic retrograde Endoscopic retrograde cholangiopancreatography (ERCP) is cholangiopancreatography (ERCP) is diagnostic to visualize stone in the bile diagnostic to visualize stone in the bile ductsducts

Percutaneous transhepatic Percutaneous transhepatic cholangiography (PTC) may also be cholangiography (PTC) may also be used to visualize the ducts; used to visualize the ducts; however, this is a more invasive however, this is a more invasive test than ERCPtest than ERCP

HIDA scan may show biliary duct HIDA scan may show biliary duct obstruction but is less useful than obstruction but is less useful than other diagnostic tests in the other diagnostic tests in the presence of elevated bilirubinpresence of elevated bilirubin

Treatment / ManagemntTreatment / Managemnt Treatment is directed at removing the Treatment is directed at removing the

obstructing bile duct stone and removing the obstructing bile duct stone and removing the gallbladder and its stones to prevent further gallbladder and its stones to prevent further stone migration into the biliary treestone migration into the biliary tree

Laparoscopic cholecystectomy with common Laparoscopic cholecystectomy with common bile duct exploration and extraction of stone(s) bile duct exploration and extraction of stone(s) may be attempted; however, conversion to an may be attempted; however, conversion to an open procedure is often necessaryopen procedure is often necessary

ERCP with basket stone retrieval and ERCP with basket stone retrieval and papillotomy may alternatively be donepapillotomy may alternatively be done- ERCP is succesessful at clearing the ducts in - ERCP is succesessful at clearing the ducts in 90% of cases90% of cases- Elective cholecystectomy (laparoscopic or - Elective cholecystectomy (laparoscopic or open) open) should follow ERCP decompressionshould follow ERCP decompression

Prognosis / ComplicationsPrognosis / Complications There is a 5-10% incidence of retained There is a 5-10% incidence of retained

stones following surgical or ERCP stone stones following surgical or ERCP stone removalremoval

Retained stones may be treated by Retained stones may be treated by chemical dissolution or biliary-enteric chemical dissolution or biliary-enteric bypass (e.g., bypass (e.g., choledochoduodenostomy, choledochoduodenostomy, choledochojejunostomy)choledochojejunostomy)

Complications of ERCP include Complications of ERCP include pancreatitis and perforation of the pancreatitis and perforation of the duodenumduodenum