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Surgical Procedures/Abdominal Surgery/Choledocholithiasis
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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.