Choledocholithiasis: causes, symptoms, diagnosis, treatment

Choledocholithiasis is the formation or presence of stones in the biliary tract. Choledocholithiasis can cause seizures of biliary colic, biliary obstruction, gallstone pancreatitis, or an infection of the biliary tract ( cholangitis ).

Diagnosis of choledocholithiasis usually requires verification using magnetic resonance cholangiopancreatography or ERCP. Timely endoscopic or surgical decompression is indicated.

[1], [2], [3], [4]

What causes choledocholithiasis?

Primary stones (usually pigmented) can form in the biliary tract. Secondary stones (usually cholesterol) are formed in the gallbladder, and then migrate to the biliary tract. Forgotten stones not found during cholecystectomy. Recurrent stones are formed in the ducts more than 3 years after surgery. In developed countries, more than 85% of choledoch stones are secondary; cholelithiasis was also diagnosed in these patients. At the same time, 10% of patients have cholelithic symptoms associated with choledoch stones. After cholecystectomy, brown pigment stones can form due to the stagnation of bile (for example, postoperative strictures) and infections. There is a direct correlation between the formation of duct pigment calculus with an increase in time after cholecystectomy.

Causes of biliary obstruction (except for stones and tumors):

• Damage to the ducts during surgery (most often)
• Scarring as a result of chronic pancreatitis
• Obstruction of the duct as a result of external compression by the cyst of the common bile duct (choledochocele) or pancreatic (rarely) pseudocyst
• Extrahepatic or intrahepatic stricture as a result of primary sclerosing cholangitis
• AIDS-induced cholangiopathy or cholangitis; direct cholangiography may show a picture similar to primary sclerosing cholangitis or papillary stenosis; possible infectious etiology, most likely cytomegalovirus infection, Cryptosporidium or Microsporidia
• Clonorchis sinensis can cause obstructive jaundice with intrahepatic duct inflammation, proximal stasis, calculus formation and cholangitis (in Southeast Asia)
• Migration of Ascaris lumbricoides to the common bile duct (rare)

Symptoms of choledocholithiasis

Stones of the biliary tract may migrate to the duodenum asymptomatically. Biliary colic develops in case of violation of their progress and partial obstruction. A more complete obturation causes dilatation of choledochus, jaundice and, ultimately, the development of a bacterial infection (cholangitis). Stones blocking the papilla faterov can cause gallstone pancreatitis. In some patients (usually elderly people), biliary obstruction with stones may develop without prior symptoms.

Acute cholangitis in obstructive lesions of the biliary tract is initiated by duodenal microflora. Although the majority (85%) of cases is due to concretions of the biliary tract, obstruction of the biliary tract may be caused by tumors or other causes. Microflora is mainly represented by Gram-negative microorganisms (for example, Escherichia coli Klebsiella Enterobacter); more rarely, gram-positive microorganisms (for example, Enterococcus) and mixed anaerobic microflora (for example, Bacteroides Clostridia). Symptoms include abdominal pain, jaundice, fever and chills (Charcot triad). On palpation, pain in the abdomen, enlarged and painful liver (abscesses are often formed) are determined. Confusion and hypotension are manifestations of neglect of the process, and mortality is approximately 50%.

[5], [6], [7], [8], [9]

Diagnosis of choledocholithiasis

Choledoch stones should be suspected in patients with jaundice and biliary colic. Functional hepatic tests and instrumental examinations should be performed. The diagnostic value of increased levels of bilirubin, alkaline phosphatase, ALT and gammaglutamyltransferase, characteristic of extrahepatic obstruction, especially in patients with signs of acute cholecystitis.

Ultrasound And can verify stones in the gallbladder and sometimes in the common bile duct. The choledoch dilated (> 6 mm in diameter if the gallbladder was not removed;> 10 mm after cholecystectomy). If the choledoch expansion is absent (for example, on the first day), then the stones probably migrated. If doubt remains, more informative magnetic resonance cholangiopancreatography (MRCP) should be performed to diagnose residual calculi. ERCP is performed in case of uninformativeness of MRCP; This study can be both therapeutic and diagnostic. CT scan is less informative than ultrasound.

If acute cholangitis is suspected, a complete blood count and blood culture should also be performed. Leukocytosis is characteristic, and an increase in aminotransferases to 1000 IU / L implies an acute necrosis of the liver, mainly due to microabsorption. When choosing an antibiotic, one should be guided by the results of blood culture.

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Treatment of choledocholithiasis

When biliary obstruction is detected, an ERCP must be performed with concrement and sphincterotomy. Laparoscopic cholecystectomy, which is not entirely suitable if it is necessary to perform intraoperative cholangiography or in general for the study of the common bile duct, can be performed strictly individually after ERCP and sphincterotomy. Open cholecystectomy with the study of the common bile duct carries with it a higher mortality rate and a more severe postoperative course. For patients with a high surgical risk of cholecystectomy, for example for the elderly, sphincterotomy is the only alternative.

Acute cholangitis is a disease that requires emergency care, active complex therapy and urgent removal of stones through endoscopic or surgical means. Antibiotics are prescribed as in acute cholecystitis. More preferred alternative drugs are imipenem and ciprofloxacin; Metronidazole is prescribed to very severe patients for exposure to anaerobic infection.