Name
CHOLEDOCHOLITHIASIS
DESCRIPTION
DETAIL
CAUSES β’ Chronic hemolytic states β’ Hepatobiliary parasitism β’ Duct stricture β’ Gallbladder disease -------------------------------------------------------------------------- DIFFERENTIAL DIAGNOSIS β’ Biliary stricture β’ Narrowed biliary - enteric anastomosis β’ Sclerosing cholangitis β’ Sphincter of Oddi dysfunction β’ Biliary parasites β’ Papillary stenosis β’ Blood clotsβ’ Increasing WBC β’ Increasing alkaline phosphatase β’ Hypercholesterolemia (when associated with chronic cholestasis) β’ Increased transaminases β’ Hyperbilirubinemia SPECIAL TESTS : β’ Nuclear medicine (PIPIDA) β’ Endoscopic retrograde cholangiopancreatography (ERCP), β’ Percutaneous transhepatic cholangiography (PTC) β’ Endoscopic ultrasound (EUS) β’ Magnetic resonance cholangiopancreatography (MRCP) IMAGING: β’ Intraoperative cholangiography - common bile duct filling defects β’ Nuclear medicine cholescintigraphy β’ Endoscopic cholangiography or PTC - common bile duct filling defects β’ Endoscopic ultrasonography - can likely detect stones, but no therapeutic capability DIAGNOSTIC PROCEDURES: β’ Ultrasound will reveal gallbladder stones - not reliable for common bile duct stones, but may reveal ductal dilatation over 75% of the time β’ ERCP will visualize the common bile duct and other portions of the upper gastrointestinal tract and will allow for papillotomy plus stone extraction in majority of cases.
TYPENOTES
RISK FACTORS β’ Cholelithiasis β’ Obesity β’ Chronic hemolysis β’ Prior cholecystectomySURGICAL MEASURES : β’ In the elderly, ERCP and papillotomy with stone removal may prevent or delay the need for cholecystectomy β’ Identification and removal of stones in the course of cholecystectomy β’ If the gallbladder has been previously removed, ERCP, papillotomy plus stone extraction DRUG(S) OF CHOICE: . Antibiotic regimen should cover gram negative aerobes, enterococci, and anaerobes if infection is present . Ampicillin 1 gm q6h IV (substitute ciprofloxacin or levofl oxacin in penicillin allergic patient) + . Aminoglycoside (e.g., tobramycin, amikacin is an alternative but is expensive) + . Metronidazole 500 mg q8h IV ALTERNATIVE DRUGS: β’ Piperacillin-tazobactam (Zosyn) OR β’ Ampicillin-sulbactam (Unasyn) OR β’ Ticarcillin-clavulanate (Timentin) PATIENT MONITORING : Routine postoperative care. Liver function tests and bilirubin levels may be beneficial. PREVENTION/AVOIDANCE : β’ Operative cholangiography at time of cholecystectomy to identify common bile duct stones and then duct exploration or endoscopic sphincterotomy for their removal β’ T-tube cholangiogram before removal of tube after operative bile duct exploration POSSIBLE COMPLICATIONS: β’ Cholangitis - most frequent (60%) β’ Bile duct obstruction β’ Pancreatitis β’ Biliary enteric fistula β’ Hemobilia β’ Liver dysfunction EXPECTED COURSE/PROGNOSIS: Good prognosis if treated
RELATED DISEASE
Not Available Disease
DISEASE
INVESTIGATION
ULTRA SOUND WHOLE ABDOMEN - FEMALE, COMPLETE BLOOD COUNT, ERCP, LIPIDS PROFILE, LIVER FUNCTION TEST