Surgical Procedures/Abdominal Surgery/Choledocholithiasis

(Stones in the common bile duct)

Introduction: edit

  • 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: edit

  • 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: edit

Clasically seen in common-bile-duct-stone.

Fluctuating Jaundice + Pain RUQ + Fever (with rigors)

Examination: edit


  • Icterus (+).
  • Febrile.


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

Investigations: edit

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

Radiological investigations: edit

  • 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: edit

  • 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: edit

    • 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: edit

  • Operated when Jaundice is not present.

Operation of Choice:

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

PostOperative Treatment: edit

  • 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.