© Springer International Publishing Switzerland 2016
Abe Fingerhut, Ari Leppäniemi, Raul Coimbra, Andrew B. Peitzman, Thomas M. Scalea and Eric J. Voiglio (eds.)Emergency Surgery Course (ESC®) Manual10.1007/978-3-319-21338-5_1515. Choledocholithiasis [Common Bile Duct (CBD) Stones]
(1)
Service Surgery, Division of General, Visceral and Vascular Surgery, University Hospital Jena, Jena, Germany
(2)
Department of Surgical Research, Clinical Division for General Surgery, Medical University of Graz, Graz, Austria
Objectives
Describe the common clinical manifestations of common bile duct stones.
Outline the management options of CBD stones.
Explain the treatment strategies in different scenarios of CBD stones.
15.1 Introduction
Choledocholithiasis is defined as the presence of gallstones in the common bile duct (CBD). An estimated 10–18 % of patients undergoing a laparoscopic cholecystectomy because of cholecystolithiasis (stones in the gallbladder) also have choledocholithiasis. The underlying pathology of choledocholithiasis is most frequently cholecystolithiasis; however, residual stones as well as denovo choledocholithiasis may also occur several weeks to several years after cholecystectomy.
Emergency treatment is necessary when signs and symptoms occur; choledocholithiasis is often clinically and biologically silent.
15.2 Diagnostic Pathways
15.2.1 Tools
Blood tests may show elevated alkaline phosphatase, gamma-glutamyl transferase, and (direct) bilirubin.
Abdominal ultrasonography (US) is inexpensive, without any side effects (e.g., radiation). Sensitivity in the detection of choledocholithiasis, although very operator dependent, ranges between 38 and 82 %. US helps diagnose concomitant cholecystitis.
Preoperative endoscopic retrograde cholangiography (ERC) offers diagnostic and therapeutic options with high sensitivity and specificity; sometimes multiple procedures are necessary.
Magnetic resonance cholangiography (MRC) is associated with sensitivity and specificity ranging between 93–100 % and 96–100 %. Although abdominal computed tomography is not the best diagnostic tool for choledocholithiasis, it is often used to eliminate other disease.
15.2.2 Leading Symptoms
Patients with choledocholithiasis can present with signs of incomplete or complete obstruction of the common bile duct or biliary pancreatitis.
Incomplete obstruction: acute crampy abdominal pain associated with vomiting and nausea. The abdomen is usually soft without generalized or localized peritoneal signs and patients are afebrile.
Complete obstruction: usually characterized by jaundice, fair stools, and dark urine, more rarely by itching.
Cholangitis is characterized by the classical triad of Charcot including right upper quadrant pain, fever, and jaundice.
Acute cholangitis occurs as a result of bacterial infection superimposed on obstruction of the biliary tree.
Severe cholangitis may be associated with hepatic microabscesses that usually carry a poor prognosis.
Biliary pancreatitis: usually presenting with diffuse abdominal pain, elevation of pancreatic enzymes, signs of inflammation and – in severe cases – pancreatic necrosis and multiorgan failure (associated with high mortality).
15.3 Interventions and Indications
1.
ERCP, usually performed with papillotomy.
Requires experienced endoscopist, sedation, or general anesthesia.
Post-interventional complications include:
Mortality: 0.5 %,
Bacteriemia: 13.3 %
Acute cholangitis: 4.1 %
Pancreatitis: 6.2 %
If impossible, surgery (ideally laparoscopic) is the best alternative.
In patients having undergone endoscopic removal of CBD stones, a laparoscopic cholecystectomy should be performed within 1 week after endoscopic treatment to avoid recurrent biliary complications and repeated hospital admissions.
2.
Surgery (removal of CBD stones).
Can be performed laparoscopically or in open surgery.
Laparoscopic choledochotomy requires advanced laparoscopic skills but has good clearance rates and has been recently shown to be as effective as open surgery in the emergency setting.
Both require general anesthesia.
Extraction of stones can be performed via the cystic duct or choledochotomy.
Decision whether to perform vertical or horizontal choledochotomy depends on size of stone and CBD, inflammatory status, and also surgeon preference.
Extraction can be done either with a balloon dilatation (or Fogarty) catheter or, better with a Dormia basket catheter, inserted through the cystic or the choledochotomy, and for the latter, with or without a small-diameter choledochoscope.
Surgery may be hampered by aberrant anatomy, proximal stones, strictures, and large or numerous stones.
The open bile duct may be addressed with closure over a T-tube, an exteriorized transcystic drain, or primary closure with or without endoluminal drainage (preferred).
At the end of the procedure, a completion cholangiography should confirm that the common bile duct is free of stones.Related posts:
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