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Tuesday, April 12, 2011

CHOLEDOCHOLITHIAISIS

Stones in the common bile duct occur in 10-155 of patients with gallstones.
These secondary stones account for more than 80% of common bile duct stones, migrate from the gallbladder, and are similar in appearance and chemical composition to the stones found there. Primary bile duct stones may develop many years after a cholecystectomy and represent the accumulation of biliary sludge consequent upon dysfunction of the sphincter pf Oddi. In far Eastern countries where bile duct infection is common, primary common bile duct stones are thought to follow bacterial infection in the biliary tree secondary to parasitic infections with Clonorchis sinensis, Ascaris lumbricoides or Fasciola hepatica. A stone in the common bile duct can cause partial or complete bile duct obstruction which may be complicated by secondary bacterial infection, cholangitis, liver abscess and speticaemia.
Clinical features
Choledocholithiasis may be asymptomatic or manifest as recurrent abdominal pain with or without jaundice. The pain is usually in the right upper quadrant and fever, pruritus and dark urine may be present, painless jaundice is uncommon. Physical examination may show the scar of a previous cholecystectomy; if the gallbladder is present it is usually small. fibrotic and impalpable.
Investigation
Liver function tests show a cholestatic pattern and bilirubinuris is present. Occasionally these tests are normal. If cholangitis is present the patient will have a leukocytosis. The most convenient method of demonstrating obstruction to the common bile duct is by ultrasonography which will demonstrate dilated extra and intra-hepatic bile duct together with gallstones, but it is not always successful in indicating the cause of the obstruction. Endoscopic retrograde cholangiography has the advantage that not only can a diagnosis be made of obstruction and its cause, but common bile duct stones can be removed. Per cutaneous trans hepatic colangiography may also be used but it is less satisfactory.
Management
Patients require stone removal either surgically or by endoscopic sphincterotomy. Cholangitis requires intravenous fluids and broad-spectrum antibiotics such as cefotaxime and metronidazole. Blood cultures should be taken before the antibiotics are administered.
Biliary drainge and the removal of the gallstones can be achieved either at choledochotomy or using endocholangiography.


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