Surgical Procedures/Abdominal Surgery/Choledocholithiasis

Choledocholithiasis:
(Stones in the common bile duct)

Introduction:

• In 10% of cases stones are found in the common bile duct.
• Stones may form within the bile ducts.
  • Known as primary Bile ducts stones.
• In majority of cases stones migrate from gall bladder.
  • Known as secondary bile duct stones.

Clinical Features:

• Symptomatic.
  • Rerely asymptomatic.
    • e.g. Vague indigestion.
• Pain:
  • Biliary Colic.
• Jaundice:
• Fever:
  • Chills and fever are usually associated with pain abdomen.

• Other symptoms:
  • clay color stool.
  • Dark urine.
  • Symptoms associated with Pancreatitis.

Charcot's Triad:

Clasically seen in common-bile-duct-stone.

Fluctuating Jaundice + Pain RUQ + Fever (with rigors)

Examination:

O/E:

• Icterus (+).
• Febrile.

P/A:

• RUQ tenderness.
• NB! Gall bladder not palpable.
  • "Courvoisier's Law".

Investigations:

• Blood:
  • WBC: Normol. (Elevated when Cholangitis.)
  • Alkaline Phosthotase: Very high in Obstructive jaundice.
  • Serum billirubin: High.
  • Serum Alylase: High when associated pancreatitis.

Radiological investigations:

• USG-Abdomen:
  • Ultra sound Should be done:
    • To know CBD size. (Normol ~8mm)
  • To detect common duct stones.

• PTC:
  • ERCP is prefered.

• ERCP:
  • Indication:
    • Sufferer with jaundice.
  • Advantages:
    • Shincterotomy.
    • Papillotomy.
    • stone removal.

Complication:

• Suppurative Cholangitis:
  • Dangerous condition which will give liver failure and death if not timely *surgical intervention and antibiotic therapy.
• Impairment of Liver function:
  • White Bile/Surgical Bile:
    • Seen when liver function is seriously depressed.
• Hydro-Hepatis:
  • Rare condition.
• Stone may ulcerate:
  • Through the common bile duct to cause biliary peritonitis.
• Natural cure:
  • Rarely stone may ulcerate through the bile duct into the duodenumto cause natural cure.
• Acute Panrcreatitis.

PreOperation Treatment:

• • AntiBiotic:
    • Broad Spectrum.
  • Analgesics.
  • AntiCholinergic:
    • Relaxant of Shincter of Oddi.
  • Vitamin K.
  • Glucose Drink.
  • High Carbohydrate with Low fat Diet.
  • Blood Transfusion:
    • To be used during Operation.
  • Mannitol.

Surgery:

• Operated when Jaundice is not present.

Operation of Choice:

• Cholecystectomy.
• Choledochotomy:
  • Supra-duodenal Choledochotomy.
  • Retro-duodenal Cholodochotomy.
  • Trans-duodenal Choledochotomy.

PostOperative Treatment:

• T-tube/drainage:
  • Regular Bile examination:
    • Color and quantity.
  • If bile was White Bile, it's color should be normol within 2 days.
  • The quantity of drainage Bile should decrease.
• Tube-Out after 7 to 10 days if:
  • T-Tube Cholangiography/PostOP. Cholangiography:
    • Should be performed before the T-tube removal.
  • When Tube is clamped and if no pain around gallbladder.
  • There is no obstruction in the bile duct.
• Small silk suture at the edge of the wound and T-Tube pulled out.

• Color Of faeces:
  • Pale or White:
    • When there is obstruction.
  • Normol yellow hue:
    • When there is no obstruction.