DISORDERS OF THE BILE DUCTS (CHOLEDOCHUS)

CHOLEDOCHOLITHIASISCHOLANGITISTREATMENT OF COMMON DUCT STONES

STRICTURES AND BENING OBSTRUCTIVE DISORDERS OF THE BILE DUCTSTUMORS OF THE BILIARY TRACTUNCOMMON CAUSES OF BILE DUCT OBSTRUCTION

Congenital Choledochal Cysts, Caroli’s Disease,Hemobilia, Pancreatitis, Ampullary Stenosis, Recurrent Pyogenic Cholangitis (Oriental Cholangiohepatitis),Sclerosing Cholangitis

CHOLEDOCHOLITHIASIS 1Biliary painJaundiceEpisodic cholangitisGallstones in gallbladder or previous cholecystectomy

General Considerations15 % of patients with stone in the gallbladder

are found to harbor calculi within the bile ducts5 % gallbladder is empty. (Otoctone stones)50 % patients with CBD stones remain asymptomatic

Dilatation of CBD less marked

CHOLEDOCHOLITHIASIS 2

Clinical FindingsA) Symptoms

AsymtomaticBiliary colicCholangitisPruritus

B) SignsIcter, tenderness, fever, chills, toxic

CHOLANGITIS (Bacterial Cholangitis)Acute cholangitis is an entity characterized by fever, chills, upper abdominal pain and jaundiceSome degree of biliary ductal obstruction andincreased intraductal pressuresThe important principle is that any case of cholangitis can progress to shock and can be fatal ifneglected

Charcot triad= Acute cholangitisAbdominal pain, jaundice, fever

Reynolds’ pentad= Toxic cholangitis+ Confusion and hypotension

CAUSES OF ACUTE CHOLANGITIS 1

GallstonesBile duct stricture

Benign causes (bile duct injury, anastomotic stenosis)Oriental cholangiopathyCongenital anomalies (Choledochal cysts Caroli’s diseaseBile duct atresia)Malignant causes

CholangiocarcinomaPancreatic causesPeriampullary and duodenal carcinomaExtrinsic compression of the bile duct

Parasitic infectionsClonorchis sinensisAscaris lumbricoides

CAUSES OF ACUTE CHOLANGITIS 2

HemobiliaIatrogenic

PTC or retrograde cholangiography (ERC)Indwelling biliary catheter or endoprosthesisBile duct ischemia

ORGANIMS ISOLATED FROM THE BILE IN CHOLANGITIS

Gram-negative bacteriaKlebsiella species 54 %Esherichia coli 39 %Enterobacter species 34 Psedomonas species 24 Citrobacter species 21

Gram-positive bacteriaEnterococcus 34Streptococcal species 38

AnaerobesBacteriodes species 15

CHOLEDOCHOLITHIASIS 3

Labaratory Findings:Leukocytosis ≥ 15.000/ μLBilirubin (2-4) < 10 mg/dLAlkaline phosphatase ↑SGOT (AST) and SGPT (ALT) ↑

DiagnosisUS (Dilatation of the CBD-MR Cholangiogram)ERCP

CHOLEDOCHOLITHIASIS 4

Complications:Multipl intrahepatic abscesses

TreatmentCholangitis should be treated with systemic antibiotics

SeftazidimTazlocilline

ERCP (sphincterotomy and stone extraction or temporarystenting or NBD and reintervention)Laparotomy

Cholecystectomy + CholedochotomyT tube or choledochoducdenostomy or transduodenalsphincteroplasty

BENING BILIARY STRICTURES

BILE DUCT CANCER 1

1 per 100.000 Frequency95 % are epithelial adenocarcinomas(chalangiocarcinomas) predominating in theextrahepatic biliary tree.Slow-growing tumorsSpread locally and by way of lymphaticsKlatskin’s tumor (hilar cholangiocarcinoma)

BILE DUCT CANCER 2

DiagnosisPainless jaundiceCourvoisier’s sign (distal tumor)Bilurubin > 10 mg/dLAlkaline phosphatase ↑, K glutamyltranferaseCA 19-9 ↑US, spiral CT, MR CholangiograpyPTCERC end stenting