CHOLEDOCHOLITHIASIS

CHOLEDOCHOLITHIASIS stones in common bile duct   Signs and symptoms 50% asymptomatic tenderness in RUQ or epigastriu...

CHOLEDOCHOLITHIASIS

• stones in common bile duct

 

Signs and symptoms

1. 50% asymptomatic
2. tenderness in RUQ or epigastrium biliary pain with intermittent chills, fever or fluctuating jaundice
3. episodic cholangitis
4. spectrum from healthy to icterus, toxicity, high fever and chills

 

Diagnostic investigations

1. increased bilirubin (<10), ALP
2. leukocytosis often > 20 x 10⁹/L
3. U/S - duct dilatation, does not detect CBD stones
4. ERCP (if no previous cholecystectomy) otherwise PTC appropriate

 

Treatment

1. antibiotics, NG tube, IV hydration
2. if no improvement in 2-4 days then ERCP/PTC+sphincterotomy or surgery with CBD exploration and laparoscopic cholecystectomy

 

 

DIAGNOSTIC EVALUATION OF BILIARY TREE

 

U/S is diagnostic procedure of choice

 

Oral cholecystography

1. Opaque drug taken night before, look for filling defect (stones)
2. failure of gallbladder to opacify indicative of complete obstruction by stone or unable to concentrate because of inflammation

HIDA scan

1. radioisotope technetium excreted in high concentrations  in bile
2. highly suggestive of acute cholecystitis when gallbladder not visualized due to cystic duct obstruction 4 hours after injection reliable when bilirubin > 20

PTC

1. injection of contrast via needle passed through hepatic parenchyma
2. useful for proximal bile duct lesions or when ERCP fails
3. antibiotic premedication always, contraindicated with cholangitis

ERCP -(Endoscopic Retrograde Cholangiopancreatography)

1. opacification of bile and pancreatic ducts possible
2. preferred method to demonstrate CBD stones and periampullary region