Choledocholithiasis Pathophysiology Complications Diagnosis Treatment 1.
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Transcript of Choledocholithiasis Pathophysiology Complications Diagnosis Treatment 1.
Choledocholithiasis
Pathophysiology
Complications
Diagnosis
Treatment1
PATHOPHYSIOLOGY
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• Primary formation of stones in the CBD*Primary calculi arising de novo in the ducts are
usually pigment stones developing in patients with:
(1) hepatobiliary parasitism or chronic, recurrent cholangitis(2) congenital anomalies of the bile
ducts (3) dilated, sclerosed, or strictured ducts(4) an MDR3 gene defect leading to
impaired biliary phospholipids secretionHarrison’s Principles of Internal Medicine, 17th ed.
PATHOPHYSIOLOGY
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PATHOPHYSIOLOGY
• Passage of gallstones into the CBD
- Majority of bile duct stones are cholesterol stones from the gallbladder w/c migrated into the extrahepatic biliary tree via the cystic duct
• Undetected duct stones left behind in cholecystectomy patients
Harrison’s Principles of Internal Medicine, 17th ed. 4
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PATHOGENESIS OF GALLSTONES
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COMPLICATIONS
Cholangitis
Obstructive Jaundice
Pancreatitis
Secondary Biliary Cirrhosis
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CHOLANGITIS
• May be acute or chronic inflammation – caused by at least partial obstruction to the
flow of bile
• Bacteria are present on bile culture in 75% of patients
• CHARCOT’S TRIAD – biliary pain– jaundice – spiking fevers with chills
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CHOLANGITIS
– Nonsuppurative acute cholangitis • most common and respond rapidly to antibiotics
– Suppurative acute cholangitis • Pus in completely obstructed ductal system
symptoms of severe toxicity such as mental confusion and septic shock
• Poor response to antibiotics and mortality is 100% unless prompt endoscopic or surgical relief of the obstruction and drainage of infected bile are carried out.
ERCP with endoscopic sphincterotomy9
OBSTRUCTIVE JAUNDICE
Biliary Obstruction Increase intrabiliary pressure
Progressive dilation of intrahepcatic bile ducts
Suppressed hepatic bile flow
Reabsorption and regurgitation of conjugated bilirubin into the
bloodstream
JAUNDICE, bilirubinuria, acholic stools 10
• Biliary obstruction may be due to:
Choledocholithiasis Underlying MalignancyChronic calculous cholecystitisIndistensible gallbladder Distended, palpable
gallbladder
Serum bilirubin level >85.5 μmol/L but seldom over 256.5 μmol/L
Serum bilirubin level ≥342.0 μmol/L
Elevated serum alkaline phosphatase
Elevated serum alkaline phosphatase
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PANCREATITIS• complicates over 30% of Choledocholithiasis
cases– Due to passage of gallstones through the common
duct
• Should be suspected in patients who develop:– Back pain or pain to the left of the abdominal midline– Prolonged vomiting with paralytic ileus– Pleural effusion, especially on the left side
• Resolves upon surgical treatment of gallstones
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SECONDARY BILIARY CIRRHOSIS
• May complicate prolonged or intermittent duct obstruction with or without recurrent cholangitis
• More common in cases of prolonged obstruction from stricture or neoplasm
• May be progressive even after correction of the obstructing process
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DIAGNOSIS AND MANAGEMENT
CHOLEDOCHOLITHIASIS
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DIAGNOSIS
• Preoperative Cholangiography– Endoscopic Retrograde
Cholangiopancreatography (ERCP) – Provides stone clearance– Defines anatomy of biliary tree
• Intraoperative Cholangiography– If patient undergoes cholecystectomy– 15% patients undergoing cholecystectomy will
prove to have CBD stones15
MANAGEMENT
• ERCP and Laparoscopic cholecystectomy lowers the incidence of complications from choledocholithiasis.
• Endoscopic Biliary Sphincterotomy followed by Spontaneous Passage or Stone Extraction
• Lifestyle Changes16
Patient’s History Ultrasound and Lab Findings
Jaundice• tea colored urine• icteric sclera
CBD size (12 mm) with dilated intrahepatic ducts
ALT
Alkaline Phosphatase
Total bilirubin
In Comparison with the Clinical Presentation of
Choledocholithiasis
Obstructive Jaundice17
Patient’s History Patient’s Ultrasound and Lab Findings
Jaundice• tea colored urine• icteric sclera
CBD size (12 mm) with dilated intrahepatic ducts
ALT
Alkaline Phosphatase
Total bilirubin
Choledocholithiasis
In Comparison with the Clinical Presentation of
Choledocholithiasis
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Patient’s History Ultrasound and Lab Findings
Jaundice• tea colored urine• icteric sclera
CBD size (12 mm) with dilated intrahepatic ducts
ALT
Alkaline Phosphatase
Total bilirubin
Risk Factor For Choledocholithiasis – Primary Calculi arising de novo in ducts
In Comparison with the Clinical Presentation of
Choledocholithiasis
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Patient’s History Ultrasound and Lab Findings
Jaundice• tea colored urine• icteric sclera
CBD size (12 mm) with dilated intrahepatic ducts
ALT
Alkaline Phosphatase
Total bilirubin
Choledocholithiasis as Differential Diagnosis
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THANK YOU!
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