short and to the point presentation of management choledocholithiasis

1. SHER-E-KASHMIR INSTITUTE OF MEDICAL SCIENCES
DEPARTMENT OF GENERAL SURGERY
INVESTIGATIONS AND MANAGEMENT OF
OBSTRUCTIVE JAUNDICE SECONDARY TO
STONE DISEASE
MODERATOR: PROF FAZL Q PARRY
PRESENTER: IFRAH AHMAD QAZI

2. DEFINITION
 Jaundice – derivative of ‘ Jaune’ meaning yellow
 Yellowish discolouration of skin ,sclera, mucous
membrane
 Clinically detected at bilirubin levels > 3.5 g/dl

4. BILIRUBIN
METABOLISM
Heme
Biliverdin
Unconjugated
bilirubin
Conjugated
bilirubin
Urobilinogen
Stercobilin
Globin
Heme oxygenase
Biliverdin reductase
UDPGT
Intestinal bacteria
LIVER
INTESTINE
KIDNEY
Urinary
Urobilinogen

5. CLASSIFICATION
 Prehepatic jaundice
 Hepatic jaundice
 Post hepatic jaundice/ Obstructive jaundice/
Surgical jaundice

6. OBSTRUCTIVE JAUNDICE
 Obstructive jaundice is interruption to the drainage of bile
in the biliary system
Symptoms
 Yellowish discolouration
 Clay coloured stools
 Tea coloured urine
 Pain abdomen
 Fever
 Pruritis

7. Signs
 Scratch marks
 Hepatomegaly
 Distended palpable GB
 Abdominal distension
 Dilated abdominal veins
 Edema

8. CAUSES OF OBSTRUCTIVE
JAUNDICE
 INTRALUMINAL CAUSES
CBD stones ( most common)
Parasites ( Ascariasis)
 TRANSMURAL CAUSES
Cholangiocarcinoma
Choledochal Cyst
Strictures
 EXTRALUMINAL CAUSES
Ca head of pancreas
Periampullary tumour
Lymph node
Mirrizi Syndrome
Accidental ligation of CBD

9. EFFECTS OF OBSTRUCTIVE
JAUNDICE
Alteration in:
 Systemic and renal hemodynamics
 Hepatic function ( protein synthesis,
reticuloendothelial function,hepatic metabolism)
 Hemostatic mechanism
 Immune function
 Wound healing

10. MANAGEMENT
Objectives
 To establish cause.
 To plan appropriate intervention.
 To prevent complications.
 To prevent recurrence.

11. INVESTIGATIONS
 Biochemical test
 Imaging Studies

12. BIOCHEMICAL TESTS
These tests can be used to:
 Detect the presence of liver disease
 Distinguish between various types of liver disorders
 Gauge the extent of liver damage
 Follow the response to the treatment

13. Shortcomings :
 Normal in a patient with serious liver disease
 Abnormal in a patient with no liver disease
 Rarely suggest a diagnosis
 Measure only a limited no. of liver functions.
 Thus no single test enables the clinician to accurately assess
the liver’s total functional capacity
 Battery of tests used.

14.  The tests commonly employed include :
 Bilirubin
 Aminotransferases
 Alkaline phosphatase
 GGT
 Coagulogram

15. Liver Function Test
Based on excretory and
detoxification function
Based on biosynthetic
function
Serum
Bilirubin
Urine Bilirubin Globulin
Coagulation
factorsAlbumin
Normal < 1 mg/dl
Unconjugated
Conjugated (30%) *
*markedly ^ed in
Obstructive juandice
Half life 15-20
days
Serum levels not
specific for liver
function
derangements
• Mostly
synthesised in
liver
• Vit K dependent
factors II, VII, IX,
X
• PT/INR/aPTT

16. Serum Enzymes
ASPARTATE
AMINOTRANSFERASE
ALANINE
AMINOTRASFERASE
ALKALINE
PHOSPATSASE
5’
NUCEOTIDASE GGT
• Diagnosis of
hepatocellular
injury
• Mildly elevated in
obstructive
jaundice
• Present in liver, bile
duct, kidney, bone
and placenta
• Normal level 20-140
IU/L
• > 3 fold ^ in biliary
obstruction
• Not specific for liver
diseas
• ^ed in biliary
obstruction
• Not ^ed in
infancy,
pregnancy,
osteoblastic
disease of
bone
15-85 IU/L
(men)
5-55 IU/L
(women)
Increased in
diseases of
liver, biliary
tract and
pancreas

17. BILIARY IMAGING
 Role in identification and detailed assessment of major bile duct
obstruction.
 The questions to be addressed :
 Is bile duct obstruction present?
 What is the anatomical level of obstruction?
 What is the cause of the obstruction?

18. IMAGING STUDIES
 Transabdominal Ultrasonography
 Computed Tomography
 ERCP
 MRI / MRCP
 Endoscopic Ultrasonography
 PTC
 Intraoperative Cholangiography

19. TRANSABDOMINAL
ULTRASONOGRAPHY
 Initial investigation
 Non-invasive, Painless, No radiation
Exposure and provides real time images.
 Operator dependent , Visualisation may be
difficult in Obese patients, ascites, or
distended bowel

20.  71-80% accuracy for identifying cause
of obstruction
 The extrahepatic bile ducts are well
visualized by ultrasound, except for the
infraduodenal portion.

21.  Ultrasonography visualizes CBD
stones in only about 50% of
cases
 Dilatation of the CBD to a
diameter greater than 6 mm is
seen in about 75% of cases

22. COMPUTED TOMOGRAPHY
 Integral part in diagnosis of obstructive jaundice.
 Sensitivity of CT in detection of CBD stones is about 22 %
 Investigation of choice
 suspected malignancy of the gallbladder, the extrahepatic
biliary system, or nearby organs, in particular, the head of
the pancreas

23. CT CHOLANGIOGRAPHY
 Involves IV contrast agents excreted preferentially by the liver
 Excretion and subsequent passage of a contrast agent,
provides a functional dimension not obtained with
conventional magnetic resonance cholangiography.
 Demonstration of bile leaks, biliary communication with cysts
and segmental obstruction

24. CT-IVC shows a small stone
within the opacified distal
common bile duct
CECT carcinoma of the
pancreatic head.

25. MRI/MRCP
 Non invasive
 Investigation of choice for detecting biliary pathology.
 No intravenous contrast
 Purely diagnostic
 C/I pt with pacemaker, cerebral aneurism clips, other metal
implants

26. CONTD..
 MRCP uses T2-weighted imaging with parameters
designed to afford best view of bile duct
 Bile has a long T2 relaxation time and hence a high signal
intensity, so that bile ducts are easily distinguished from
vessels on heavily T2-weighted images
 Fast, effective, non-invasive way to image biliary tract
 Demonstrates ductal dilatation and strictures with 95%
sensitivity
 Sensitivity for stone visualization - 75-95%, better than CT
or US

27. CHOLEDOCHOLITHIASIS
 MRC (MR cholangiography)
 Bile: Very bright signal
 Ductal stones: Decreased signal
intensity foci
 Low-signal filling defects within
increased signal intensity bile

28. MRCP in a case of PSC showing a long
stricture( arrow)
MRCP showing dilated hepatic ducts with
tumour causing
a blockage at the confluence

29. ERCP
 Provides dynamic information during
contrast medium introduction and drainage
 CBD Stones
 Sensitivity 90-95 %
 Specificity 92-98 %
 Offers the option of intervention
 Stone extraction
 Sphincterotomy
 Placement of biliary stent

30. Advantages :
 Diagnostic and therapeutic
 Find out obstruction especially in the lower part of biliary
passage
 Opportunity to take tissue sample
Disadvantages :
 Invasive
 Bleeding, pancreatitis, cholangitis, perforation( 10 %)

31. ERCP showing multiple
calculi (filling defects) within
cystic and common bile ducts
ERCP following endoscopic
papillotomy shows a wire
basket being used to fragment,
snare and extract biliary calculi

32. ENDOSCOPIC ULTRASOUND
 Detailed imaging of organs in close
proximity to the digestive tract.
 Sensitivity (94%) and specificity (95%) --
diagnosis of choledocholithiasis
 Tissue sampling by EUS-guided fine needle
aspiration (EUS-FNA)

33.  EUS and EUS-FNA are sensitive (overall
73 %) -cholangiocarcinoma and very
specific (97%) in predicting
unresectability
 High detection rates (96%-100%) and
staging accuracy of EUS with respect to
duodenal or CBD wall involvement,
invasion of the pancreas and portal vein,
and spread to regional lymph nodes.
 More accurate than CT and MRI in tumor
staging of ampullary neoplasms (EUS
78%, CT 24%, MRI 46%).

34. PERCUTANEOUS
TRANSHEPATIC
CHOLANGIOGRAPHY
 Preferred technique
 proximal obstruction
 ERCP not possible
 Option of tissue biopsy
 Intervention with drain or stent
 Largely replaced by non-invasive techniques like MRCP
 Role in post Bilio-enteric anastamotic strictures

35. INTRAOPERATIVE
CHOLANGIOGRAPHY
 Mirizzi described the procedure in 1937
 Most commonly used during elective cholecystectomy
 assess retained stones and to provide clarification of the
biliary anatomy.
 Diagnosis :
 Choledocholithiasis
 Biliary Injury (earlier recognition and correction of biliary
injury )

36. TREATMENT

37. CONSERVATIVE
 Fluid and electrolytes
 Urine output monitoring
 Correction of coagulation defects
 Prevention of infection
 Nutrition ( enteral nutrition preferred)

38. FLUID AND ELECTROLYTE THERAPY
AND URINE OUTPUT MONITORING
 Dehydration occurs in obstructive jaundice:
 Recurrent vomitting
 Decreased intake
 Fever
 Prevention of dehydration
 Liberal fluid therapy with correction of electrolytes

39. CORRECTION OF COAGULATION
DEFECTS
 Coagulopathy due to:
 Decreased absoption of Vit K
 Liver injury
 Assessment by Prothrombin time / INR.
 Inj Vit K 10 mg i/v OD for three days ( in elective procedures)
 Trasfuse FFPs ( in emergency situation)

40. PREVENTION OF INFECTION
 Cholangitis and sepsis :
 Gram negative org ( E.coli, K. pneumonae, P. mirabilis,etc)
 Anaerobes
 Cephalosporins ( second and third generations)
 Floroquinolones
 Metronidazole

41. SURGICAL MANAGEMENT
 Definitive treatment of the obstructive jaundice.
 Varies with the cause of obstruction and condition of
patient.
 Performed in physically fit and optimised patients.

42. CHOLEDOCHOLITHIASIS

43. Pre-op diagnosis of CBD
stones
Lap(-)
ERCP(-)
Lap(-)
ERCP(+)
Lap(+)
ERCP(+)
Lap(+)
ERCP(-)
OC with
CBDE
Transfer
patient
ERCP
LC
LC with
CBDE
LC
ERCP

44. Intra-op diagnosis of
CBD stones
Lap(-)
ERCP(-)
Lap(-)
ERCP(+)
Lap(+)
ERCP(+)
Lap(+)
ERCP(-)
LC only
ERCP
LC with
CBDE

45. ERCP
 ERCP with sphicterotomy f/b extraction
 Dormia basket ( stone > 1cm)
 Balloon catheter
 Success rate 80-90 %
 Papilla and sphincter divided with a sphincterotome
 ERCP with balloon sphincteroplasty ( 6-8 mm dia balloon)
 High failure rates (22 %) and pancreatitis ( 3 fold of
sphincteroromy)

46.  In case of large stones > 1.5cm , impacted stones
 Mechanical lithotripsy
 Electrohydraulic lithotripsy
 Laser lithotripsy
 Extracorporeal shock wave lithotripsy
 Large balloon dilatation

47. Mechanical Lithotripsy:
 Most commonly used method of fragmentatation
 Basket used to trap stone f/by crushing against the metal sheath
 Success rate 80 to 90 %
 Most important factors resulting in failure :
 Stone impaction
 Stone composition : hard calcified stones resist fragmentation

48. Intraductal Shock Wave Lithotripsy:
 Done with the help of a flexible lithotripsy probe passed through
the working channel of cholangioscope
 Two types :
 Electrohydraulic lithotripsy
 Laser Lithotripsy
 Impulses are fired on stone surface under cholangioscopic
guidance
 Success rate 80-95 %

49. Extracorporeal Shock Wave Lithotripsy:
 Used in
 Patients with major medical comorbidities
 Technical difficulties in standard endoscopic stone extraction
 Multiple session are needed
 Stone targeting by either fluoroscopy or ultrasound
 Complete clearance – 90%
 Most patients require fragment extraction by endoscopy

50. Large balloon dilatation:
 When other standard methods unsuccessful
 10-20 mm diameter balloon used f/by basket/balloon extraction
 Complications 7 – 33 % :
 Cholangitis, pancreatitis, bleeding

51. ERCP WITH SPHINCTEROTOMY

52. LAPAROSCOPIC CBD
EXPLORATION
 Transcystic approach
 Trasductal approach
Transcystic CBD Exploration

53. INDICATIONS OF TRANSDUCTAL APPROACH
 Stones > 6 mm
 Intrahepatic stones
 Cystic duct diameter < 4mm
 Cystic duct entrance either posterior or distal

54. MANAGEMENT OF
CHOLEDOCHOTOMY
 Primary closure
 T-tube decompression
 Choledochoduodenostomy
 Transduodenal sphincterotomy
 Roux-en-Y choledochojejunostomy

55. CBD EXPLORATION WITH
T TUBE INSERTION

57. Indications :
 Decompression of CBD in incomplete clearence
 Residual stones
 Postoperative biliary study
 T tube cholangiogram is done usually after 7 to 10 days
 Removed usually after 10 days if no residual stones seen
 In case of residual stones , tube kept for 6 weeks
 Burhenne technique can be stones to retrieve stones under
flouroscopic guidance

58. COMPLICATIONS OF T- TUBE
 Dislodgement
 Bacteraemia
 Fracture of tube
 Bile leak and peritonitis at removal

59. TRANS DUODENAL
SPHINCTEROTOMY
 Indications :
 Impacted stone in ampulla
 Papillary stenosis
 Multiple stones with nondilated duct

60.  Ampulla localised by passing Fogarty catheter through CBD
 Longitudinal duodenotomy made
 Entrance to pancreatic duct identified
 Absorbable sutures placed on each side of ampulla
 Sphincterotomy started at 11 o’clock
 Opening made wide enough for biliary dilator of size of CBD
 Last ampullary suture placed at apex
 Duodenotomy closed in transverse direction

61. CHOLEDOCHODUODENOSTOMY
 Indications:
 Recurrent stones requiring repeated interventions
 Impacted stones
 Ampullary stenosis
 Funnel syndrome
 Side to side anastomosis most commonly used.

63. COMPLICATIONS OF
CHOLEDOCHODUODENOSTOMY
 Cholangitis
 Sump syndrome
 Wound infection
 Anastomotic leaks
 Intraabdominal abscess

64. CHOLEDOCHOJEJUNOSTOMY
 Two methods :
 Loop choledochojejunostomy
 Roux en Y choledochojejunostomy
 End – side anastomosis made
 Intestinal content reflux prevented by
 Side to side jejunojenostomy in loop CDJ
 Using 60 cm afferent Roux en Y brought retrocolic in Roux en Y
CDJ
 Anastomosis decompressed by T tube or transhepatic stents