1. Pathophysiology Complications Diagnosis Treatment
Choledocholithiasis
Pathophysiology
Complications
Diagnosis
Treatment

2. Pathophysiology

3. PATHOPHYSIOLOGY Primary formation of stones in the CBD
*Primary calculi arising de novo in the ducts are usually pigment stones developing in patients with:
(1) hepatobiliary parasitism or chronic, recurrent cholangitis
(2) congenital anomalies of the bile ducts
(3) dilated, sclerosed, or strictured ducts
(4) an MDR3 gene defect leading to impaired biliary phospholipids secretion
increases with increasing age of the patient, so that up to 25% of elderly patients may have calculi in the common duct at the time of cholecystectomy
Harrison’s Principles of Internal Medicine, 17th ed.

4. PATHOPHYSIOLOGY Passage of gallstones into the CBD
- Majority of bile duct stones are cholesterol stones from the gallbladder w/c migrated into the extrahepatic biliary tree via the cystic duct
Undetected duct stones left behind in cholecystectomy patients
in ~10–15% of patients with cholelithiasis
in ~1–5% of cholecystectomy patients
Common duct stones may remain asymptomatic for years, may pass spontaneously into the duodenum, or (most often) may present with biliary colic or a complication.
Harrison’s Principles of Internal Medicine, 17th ed.

6. PATHOGENESIS OF GALLSTONES

7. COMPLICATIONS Cholangitis Obstructive Jaundice Pancreatitis
Secondary Biliary Cirrhosis
COMPLICATIONS

8. CHOLANGITIS May be acute or chronic inflammation
caused by at least partial obstruction to the flow of bile
Bacteria are present on bile culture in 75% of patients
CHARCOT’S TRIAD
biliary pain
jaundice
spiking fevers with chills

9. CHOLANGITIS Nonsuppurative acute cholangitis
most common and respond rapidly to antibiotics
Suppurative acute cholangitis
Pus in completely obstructed ductal system  symptoms of severe toxicity such as mental confusion and septic shock
Poor response to antibiotics and mortality is 100% unless prompt endoscopic or surgical relief of the obstruction and drainage of infected bile are carried out.
ERCP with endoscopic sphincterotomy
ERCP with endoscopic sphincterotomy
- Is safe and the preferred initial procedure for both establishing a definitive diagnosis and providing effective therapy.

10. OBSTRUCTIVE JAUNDICE Increase intrabiliary pressure
Biliary Obstruction
Increase intrabiliary pressure
Progressive dilation of intrahepcatic bile ducts
Suppressed hepatic bile flow
Secondary to gradual chronic obstruction of CBD
Reabsorption and regurgitation of conjugated bilirubin into the bloodstream
JAUNDICE, bilirubinuria, acholic stools

11. Biliary obstruction may be due to:
Choledocholithiasis
Underlying Malignancy
Chronic calculous cholecystitis
Indistensible gallbladder
Distended, palpable gallbladder
Serum bilirubin level >85.5 μmol/L but seldom over μmol/L
Serum bilirubin level ≥342.0 μmol/L
Elevated serum alkaline phosphatase

12. PANCREATITIS Resolves upon surgical treatment of gallstones
complicates over 30% of Choledocholithiasis cases
Due to passage of gallstones through the common duct
Should be suspected in patients who develop:
Back pain or pain to the left of the abdominal midline
Prolonged vomiting with paralytic ileus
Pleural effusion, especially on the left side
Resolves upon surgical treatment of gallstones

13. SECONDARY BILIARY CIRRHOSIS
May complicate prolonged or intermittent duct obstruction with or without recurrent cholangitis
More common in cases of prolonged obstruction from stricture or neoplasm
May be progressive even after correction of the obstructing process

14. Diagnosis and MANAGEMENT
CHOLEDOCHOLITHIASIS
Diagnosis and MANAGEMENT

15. DIAGNOSIS Preoperative Cholangiography Intraoperative Cholangiography
Endoscopic Retrograde Cholangiopancreatography (ERCP)
Provides stone clearance
Defines anatomy of biliary tree
Intraoperative Cholangiography
If patient undergoes cholecystectomy
15% patients undergoing cholecystectomy will prove to have CBD stones

16. MANAGEMENT
ERCP and Laparoscopic cholecystectomy lowers the incidence of complications from choledocholithiasis.
Endoscopic Biliary Sphincterotomy followed by Spontaneous Passage or Stone Extraction
Lifestyle Changes

17. In Comparison with the Clinical Presentation of Choledocholithiasis
Patient’s History
Ultrasound and Lab Findings
Jaundice
tea colored urine
icteric sclera
 CBD size (12 mm) with dilated intrahepatic ducts
 ALT
 Alkaline Phosphatase
 Total bilirubin
Obstructive Jaundice

18. In Comparison with the Clinical Presentation of Choledocholithiasis
Patient’s History
Patient’s Ultrasound and Lab Findings
Jaundice
tea colored urine
icteric sclera
 CBD size (12 mm) with dilated intrahepatic ducts
 ALT
 Alkaline Phosphatase
 Total bilirubin
Choledocholithiasis

19. In Comparison with the Clinical Presentation of Choledocholithiasis
Patient’s History
Ultrasound and Lab Findings
Jaundice
tea colored urine
icteric sclera
 CBD size (12 mm) with dilated intrahepatic ducts
 ALT
 Alkaline Phosphatase
 Total bilirubin
Risk Factor For Choledocholithiasis – Primary Calculi arising de novo in ducts

20. Choledocholithiasis as Differential Diagnosis
Patient’s History
Ultrasound and Lab Findings
Jaundice
tea colored urine
icteric sclera
 CBD size (12 mm) with dilated intrahepatic ducts
 ALT
 Alkaline Phosphatase
 Total bilirubin

21. Thank you!