Choledocholithiasis

  • – 10-15% of gall stone patients passes the stone in common bile duct
  • – 25% elderly patients undergoing cholecystectomy have also choledocholithiasis. Majority of them are cholesterol stone originating in GB
  • – Prevalence of choledocholithiasis in patients with Gb stone is 5-15% depending upon age
  • – Stone primarily formed in the bile ducts are usually pigment stone
  • Complications of choledocholithiasis
  •         – Obstructive jaundice
  •         – Cholangitis
  •        – Pancreatitis
  •        – Secondary biliary cirrhosis
  • Presentation of acute obstruction of CBD
  •       – Biliary pain similar to pain of cystic duct obstruction followed by jaundice if obstruction is for sufficient
  •       – Raised ALT, AST later raised bilirubin, ALP
  • USG   
  • – If CBD diameter >6 mm: biliary stone should be suspected
  • – Endosonography has the highest sensitivity for choledocholithiasis

Management of Choledocholithiasis: 

  • – 20% stone of choledocholithiasis pass spontaneously
  • – Asymptomatic bile duct stone may be treated but that treatment is not necessary for every patient
  • – Stone fragments upto 8 mm in diameter can pass the papilla spontaneously without severe pain
  • – Patients with GB stone + simultaneous bile duct stone :     Preoperative stone extraction by ERCP is preferable
  • – In highly expert center, laparoscopic cholecystectomy and laparoscopic transcystic bile duct exploration and stone extraction may be done

 

Treatment of bile duct stone without complication

  • 1.Endoscopic sphincterotomy and stone extraction
  • 2.Intraoperative endoscopic retrograde cholangiopancreatography or laparoscopic bile duct exploration in combination of cholecystectomy when adequate expertise present

Treatment of bile duct stone by ERCP

  • – Sphincterotomy with stone extraction by balloon/basket
  • – Balloon dilation of the papilla (balloon sphincteroplasty)
  • Techniques to remove large bile duct stone
  •             – Lithotripsy
  •                        • Mechanical lithotripsy
  •                        • Intraductal lithotripsy by Laser/Electrohydraulic catheter
  • – Combination of sphincterotomy + balloon dilatation of the bile duct
  • – Biliary stenting   ⇒    If stone cannot be removed

 

Treatment of failed standard stone extraction

  • – Exrtracorporeal shock wave lithotripsy
  • – Electrohydraulic/Laser lithotripsy
  • – In altered anatomy: Percutaneous/endoscopic (balloon endoscopy assisted) treatment of bile duct stone
  • – Endoscopic balloon dilatation with a large diameter balloon is an option to facilitate the extraction of large stone

 

  • When cholecystectomy should be performed in patients with GB stone after endoscopic removal of bile duct stone?
  •         Cholecystectomy should be performed in this situation within 72 hours after ERCP for choledocholithiasis

 

Treatment of Choledocholithiasis during Pregnancy

  • Symptomatic bile duct stone should be treated by endoscopic sphincterotomy and stone extraction by experienced endoscopist

Surgical treatment:

  • – Transcholedochal approach is needed in case of large stone and stone located above the insertion of cystic duct in CBD
  • – T tube is used when
  •       The duct is small and suture closure in the absence of T-tube may lead to stricture that is difficult to dilate
  •       When stone evacuation is incomplete to allow biliary decompression and percutaneous stone extraction by          an interventional radiologist

Copyrights © 2020 Arefin | Gastroenterology | Developed by Chumbok IT