Common Bile Duct Stones
(Choledocholithiasis)
--- Content provided by FirstRanker.com ---
? May be small or large? Single or multiple
? Found in 6 to 12% of patients with stones in the gallbladder
--- Content provided by FirstRanker.com ---
? Incidence increases with age
? Secondary stones:
--- Content provided by FirstRanker.com ---
? Formed within the gallbladder and migrate down the cysticduct to the common bile duct
? Cholesterol stones
--- Content provided by FirstRanker.com ---
? Primary stones : form in the bile ducts
? Brown pigment type
--- Content provided by FirstRanker.com ---
? Associated with biliary stasis and infectionClinical Manifestations
? Silent and often are discovered incidentally
--- Content provided by FirstRanker.com ---
? May cause obstruction, complete or incomplete
? Cholangitis or gallstone pancreatitis
--- Content provided by FirstRanker.com ---
? Pain? Mild epigastric or right upper quadrant tenderness
Clinical Manifestations
--- Content provided by FirstRanker.com ---
? Mild icterus? Symptoms may also be intermittent
? Elevation of serum bilirubin, alkaline phosphatase, and
--- Content provided by FirstRanker.com ---
transaminases are commonly seen in patients with
bile duct stones
--- Content provided by FirstRanker.com ---
? However, in about one third of patients with commonbile duct stones, the liver chemistries are normal
Diagnosis
--- Content provided by FirstRanker.com ---
Investigation
Sensitivity
--- Content provided by FirstRanker.com ---
SpecificityUS
25-82%
--- Content provided by FirstRanker.com ---
56-100%
EUS
--- Content provided by FirstRanker.com ---
95 %95-98 %
MRCP
--- Content provided by FirstRanker.com ---
95 %
97 %
--- Content provided by FirstRanker.com ---
CT87 %
97 %
--- Content provided by FirstRanker.com ---
Ultrasound shows a normal or mildly dilated common bile
duct with a stone
--- Content provided by FirstRanker.com ---
ERCP shows multiple stones in the common bile duct
? Dilated CBD (>8 mm in diameter) on ultrasonography
in a patient with gallstones, jaundice, and biliary pain is
--- Content provided by FirstRanker.com ---
highly suggestive
? Magnetic resonance cholangiography (MRC) provides
--- Content provided by FirstRanker.com ---
excellent anatomic detail? Endoscopic cholangiography is the gold standard for
diagnosing common bile duct stones.
--- Content provided by FirstRanker.com ---
Management Options? CBD Stones
? Open cholecystectomy + CBD exploration
--- Content provided by FirstRanker.com ---
? ERCP + Endoscopic Sphincterotomy (followed bycholecystectomy ? most frequently used).
? Laparoscopic cholecystectomy + Laparoscopic CBD exploration
--- Content provided by FirstRanker.com ---
? in specialized centers.
? Choledochoscopy at laparoscopy or percutaneous
--- Content provided by FirstRanker.com ---
choleydochoscopy or choleydochoscopy through T tube.? ERCP has become a popular technique to clear CBD stones.
? Currently in the laparoscopic era studies have shown that
--- Content provided by FirstRanker.com ---
laparoscopic treatment of CBD stones is possible and ispotential y as effective as ERCP.
? This is most commonly done by a transcystic approach,
--- Content provided by FirstRanker.com ---
though evidence of success in large volume cohorts with a
more technical y demanding laparoscopic Choledochotomy
--- Content provided by FirstRanker.com ---
is emerging .Common Bile Duct Stricture
Causes
--- Content provided by FirstRanker.com ---
? operative injury MC by lap. cholecystectomy? fibrosis due to:
?chronic pancreatitis
?common bile duct stones
--- Content provided by FirstRanker.com ---
?acute cholangitisbiliary obstruction:
? cholecystolithiasis (Mirizzi's syndrome)
--- Content provided by FirstRanker.com ---
? sclerosing cholangitis? Cholangiohepatitis
? strictures of a biliary-enteric anastomosis
Clinical presentation
--- Content provided by FirstRanker.com ---
? Episodes of cholangitis
? Jaundice
--- Content provided by FirstRanker.com ---
? Liver function tests usually show evidence ofcholestasis
--- Content provided by FirstRanker.com ---
Diagnosis? Ultrasound / CT scan will show dilated bile ducts
proximal to the stricture
--- Content provided by FirstRanker.com ---
? MRC : anatomic information about the location
and the degree of dilatation
--- Content provided by FirstRanker.com ---
? Endoscopic cholangiogram will outline the distalbile duct
ERC showing stricture of the common hepatic duct
--- Content provided by FirstRanker.com ---
ManagementDepends on the location and the cause of the stricture
? Percutaneous or endoscopic dilatation and/or stent placement
--- Content provided by FirstRanker.com ---
give good results in more than one half of patients
? Surgery with Roux-en-Y choledochojejunostomy or
--- Content provided by FirstRanker.com ---
hepaticojejunostomy is the standard of care with good orexcellent results in 80 to 90% of patients
? Choledochoduodenostomy may be a choice for strictures in the
--- Content provided by FirstRanker.com ---
distal-most part of the common bile duct
Carcinoma Gal bladder
Etiology
--- Content provided by FirstRanker.com ---
? Accounts for 2 to 4% of malignant GI tumors
? 2-3 times more common in females than males
? 90% of patients have gallstones
? Larger stones (3 cm) are associated with tenfold
--- Content provided by FirstRanker.com ---
increased risk of cancer
? Polypoid lesions of the gallbladder (>10 mm)
? Calcified "porcelain" gallbladder >20% incidence
--- Content provided by FirstRanker.com ---
? Choledochal cysts
? Sclerosing cholangitis
? Anomalous pancreaticobiliary duct junction
? Exposure to carcinogens (azotoluene, nitrosamines)
--- Content provided by FirstRanker.com ---
Pathology? 80 and 90% of the tumors are adenocarcinomas
? papillary, nodular, and tubular
--- Content provided by FirstRanker.com ---
Squamous cell
Adenosquamous
--- Content provided by FirstRanker.com ---
Oat cellCancer of the gallbladder spreads through:
? lymphatics
--- Content provided by FirstRanker.com ---
? venous drainage
? direct invasion into the liver parenchyma
Clinical Manifestation
--- Content provided by FirstRanker.com ---
? Abdominal discomfort
? Right upper quadrant pain
--- Content provided by FirstRanker.com ---
? Nausea & vomiting? Jaundice
? Weight loss
--- Content provided by FirstRanker.com ---
? Anorexia
? Ascites
--- Content provided by FirstRanker.com ---
? Abdominal massDiagnosis
? FNAC /Biopsy (guided)
--- Content provided by FirstRanker.com ---
? Ultrasonography
? CT scan
--- Content provided by FirstRanker.com ---
? Percutaneous transhepatic or endoscopic cholangiogram(in jaundiced pt)
? MRCP
--- Content provided by FirstRanker.com ---
CT scan of a patient with gal bladder cancer
--- Content provided by FirstRanker.com ---
Staging:(AJCC 7th Edition)
Treatment
--- Content provided by FirstRanker.com ---
? Surgery :
? Radical Cholecystectomy, Liver resection with
--- Content provided by FirstRanker.com ---
regional lymphadenectomy? Radiotherapy
? Adjuvant (pT1b onwards)
--- Content provided by FirstRanker.com ---
? Chemotherapy
? Concurrent
? Adjuvant
--- Content provided by FirstRanker.com ---
? PalliativePrognosis
? 5-year survival rate of al patients <less than 5%
--- Content provided by FirstRanker.com ---
? Median survival: 6 months? T1 disease treated with cholecystectomy have an excel ent prognosis
(85 - 100% 5-year survival rate)
--- Content provided by FirstRanker.com ---
? 5-year survival rate for T2 lesions treated with an extended
cholecystectomy and lymphadenectomy compared with simple
--- Content provided by FirstRanker.com ---
cholecystectomy is over 70% versus 25 to 40%, respectively? Patients with advanced but resectable gal bladder cancer are
reported to have 5-year survival rates of 20 to 50%
--- Content provided by FirstRanker.com ---
? Median survival for patients with distant metastasis at the time of
presentation is only 1 to 3 months
--- Content provided by FirstRanker.com ---
Cholangiocarcinoma
? Rare tumor arising from the biliary epithelium
--- Content provided by FirstRanker.com ---
? May occur anywhere along the biliary tree? About 2/3rd are located at the hepatic duct bifurcation
? Male to female ratio is 1.3:1
--- Content provided by FirstRanker.com ---
? Average age of presentation is between 50 to 70 years
Etiology
--- Content provided by FirstRanker.com ---
Ulcerative ColitisThorotrast Exposure
Sclerosing Cholangitis
--- Content provided by FirstRanker.com ---
Typhoid Carrier
Choledochal Cysts
--- Content provided by FirstRanker.com ---
Adult Polycystic KidneyDisease
Hepatolithiasis
--- Content provided by FirstRanker.com ---
Liver Flukes
Papil omatosis of Bile Ducts
Distribution
--- Content provided by FirstRanker.com ---
? Right or left hepatic duct = 10%
? Bifurcation = 20%
--- Content provided by FirstRanker.com ---
? Proximal CBD = 30%? Distal CBD = 30%
Pathology
--- Content provided by FirstRanker.com ---
? Over 95% of bile duct cancers are adenocarcinomas.
? Anatomical y they are divided into distal, proximal, or
--- Content provided by FirstRanker.com ---
perihilar tumors.? Intrahepatic cholangiocarcinomas are treated like
hepatocel ular carcinoma, with hepatectomy when
--- Content provided by FirstRanker.com ---
possible.
? About two-thirds of cholangiocarcinomas are located
--- Content provided by FirstRanker.com ---
in the perihilar location? Perihilar cholangiocarcinomas, also referred to as
Klatskin tumors, are further classified based on
--- Content provided by FirstRanker.com ---
anatomic location by the Bismuth-Corlette
classification
--- Content provided by FirstRanker.com ---
Bismuth-Corlette classification
? Type I: confined to the common hepatic duct
--- Content provided by FirstRanker.com ---
? Type II: involve the bifurcation without involvementof the secondary intrahepatic ducts
? Type II A &I IB: extend into the right and left
--- Content provided by FirstRanker.com ---
secondary intrahepatic ducts, respectively
? Type IV: involve both the right and left secondary
--- Content provided by FirstRanker.com ---
intrahepatic ductsClinical Presentation
--- Content provided by FirstRanker.com ---
? Painless jaundice? Pruritus
? Mild right upper quadrant pain
? Anorexia
? Fatigue
--- Content provided by FirstRanker.com ---
? Weight loss? Cholangitis
? Elevated ALK PO4 and GGT levels
Intra and Extra-hepatic Cholangiocarcinoma
--- Content provided by FirstRanker.com ---
Diagnosis
? Ultrasound abdomen
--- Content provided by FirstRanker.com ---
? CT scan? Cholangiography : biliary anatomy is defined
? PTC
Defines the proximal extent of the tumor, which is the most
--- Content provided by FirstRanker.com ---
important factor in determining resectability.? ERC: evaluation of distal bile duct tumors
? Celiac angiography: evaluation of vascular involvement
? MRI: has the potential of evaluating the biliary anatomy,
--- Content provided by FirstRanker.com ---
lymph nodes, vascular involvement, tumor growthERCP: Distal CBD Cancer
--- Content provided by FirstRanker.com ---
MRCP of Extra-hepatic Cholangiocarcinoma at the BifurcationKlatskin tumor
Treatment
--- Content provided by FirstRanker.com ---
? Surgical excision is the only potentially
curative treatment
--- Content provided by FirstRanker.com ---
? Location and local extension of the tumordictates the extent of the resection
Bismuth-Corlette type I or II with no signs of
--- Content provided by FirstRanker.com ---
vascular involvement:? local tumor excision with portal lymphadenectomy,
cholecystectomy, common bile duct excision, and
--- Content provided by FirstRanker.com ---
bilateral Roux-en-Y hepaticojejunostomiesBismuth-Corlette type II a or II b:
? right or left hepatic lobectomy respectively should
--- Content provided by FirstRanker.com ---
also be performedDistal bile duct tumors:
? pylorus-preserving pancreatoduodenectomy
--- Content provided by FirstRanker.com ---
(Whipple procedure)Unresectable distal bile duct cancer:
? Roux-en-Y hepaticojejunostomy, cholecystectomy
--- Content provided by FirstRanker.com ---
and gastrojejunostomyRoux-en-Y Hepaticojejunostomy
--- Content provided by FirstRanker.com ---
CholangiocarcinomaExtra-hepatic Disease: Positive Margins or
Unresectable
--- Content provided by FirstRanker.com ---
? Stent and Chemo/Radiation Therapy
? 5-FU based or Gemcitabine or Clinical Trial
--- Content provided by FirstRanker.com ---
? Survival with surgery and chemo/radiation is 24 to36 m
? With chemo/radiation alone survival is 12 to 18 m.
--- Content provided by FirstRanker.com ---
CholangiocarcinomaExtra-hepatic Disease: Unstentable
? Bypass if possible
--- Content provided by FirstRanker.com ---
? If not use proximal decompression andfeeding jejunostomy
? Chemotherapy/Radiation
--- Content provided by FirstRanker.com ---
Therapy/Brachy therapy as tolerated or
clinical trial.
--- Content provided by FirstRanker.com ---
Prognosis? Best Result are with distal CBD tumors completely excised.
Cure = 40%
--- Content provided by FirstRanker.com ---
? Incomplete resection plus radiation gives a median
survival of 30 m.
--- Content provided by FirstRanker.com ---
? Stenting plus chemo/radiation gives a median survival of17 to 27m
? Those stented alone live only a few months
--- Content provided by FirstRanker.com ---