Common bile duct stones (choledocholithiasis): causes, symptoms, diagnosis, treatment

In most cases, the stones of the common bile duct migrate from the gallbladder and are combined with calculous cholecystitis. The process of migration depends on the ratio of the size of the stone and the clearance of the gallbladder and common bile ducts. The increase in the size of the stone in the common bile duct causes obturation of the latter and promotes the migration of new stones from the gall bladder.

Secondary stones (not formed in the gallbladder) are usually associated with partial obturation of the bile ducts with undeveloped stone, traumatic stricture, sclerosing cholangitis, or congenital anomalies of the biliary tract. The starting point for the formation of stone can be an infection. The stones are brown, can be single or multiple, have an oval shape and are oriented along the axis of the duct. They are usually infringed in the liver-pancreas (fater) ampoule.

Changes in choledocholithiasis

Because of the valve effect, stone obturation with the final part of the common bile duct is usually partial and transient. In the absence of jaundice, the histological picture in the liver is not changed; jaundice is accompanied by signs of cholestasis. In chronic choledocholithiasis, concentric scarring of the bile ducts is found, and as a result, secondary sclerosing cholangitis and biliary cirrhosis of Holangitis develop. Stagnation of bile promotes its infection, in particular with intestinal microflora, while bile becomes turbid, dark brown (bile putty), in rare cases - purulent. The common bile duct is enlarged, its walls are thickened, sloughing and ulceration of the mucous membrane are noted, especially in the hepatic-pancreatic ampoule. Cholangitis can spread to the intrahepatic bile ducts and with a severe long infection leads to the formation of liver abscesses, which on the cut look like communicating with the bile ducts of the cavity, filled with pus and bile. Most often with cholangitis, Escherichia coli is sown , and more rarely Klebsiella spp . , Streptococcus spp . . Bacteroides spp . , Clostridia spp .

The infringement or passage of concrements through the nipple tapers can cause acute or chronic pancreatitis.

Clinical syndromes

Choledocholithiasis can be asymptomatic and can be detected only with the help of visualization methods for cholecystectomy, undertaken with regard to chronic calculous cholecystitis. In other cases, choledocholithiasis is complicated by acute cholangitis with jaundice, pain and fever. In older people, the disease can only be manifested by mental and physical exhaustion. Unsuccessful stones of the common bile duct determine the clinical signs in the early or late periods after the operation or remain "mute".

Cholangitis with jaundice

The classical clinical picture is characterized by the appearance of jaundice, abdominal pain, chills and fever in elderly women with obesity and epigastric pain in the anamnesis, flatulence, dyspepsia, intolerance to fatty foods. Cholestatic jaundice does not develop in all patients, it may be mild or intense. Complete obturation of the common bile duct is observed rarely, which is associated with fluctuations in the level of bile pigments in the stool.

About 75% of patients complain of pain in the right upper quadrant of the abdomen or epigastric region, which have a strong cramping character with light intervals and require the use of analgesics. In some cases, constant, severe intense pains are observed. Pain radiates to the back and right shoulder blade, accompanied by vomiting. Epigastric region with palpation is painful. A third of patients experience fever, sometimes with chills. Urine is dark, its color depends on the degree of obturation of the common bile duct.

In bile cultures there is an increase in mixed intestinal microflora, mainly Escherichia coli .

The activity of alkaline phosphatase, GGTP, and conjugated bilirubin level in serum are increasing, which is characteristic of cholestasis. In acute obturation, a short-term significant increase in the activity of transaminases can be observed.

Obturation with a stone of the main pancreatic duct leads to a rapid increase in the activity of amylase, sometimes in the presence of clinical symptoms of pancreatitis.

Hematologic changes. The number of polymorphonuclear leukocytes is increased depending on the severity and severity of cholangitis.

The blood cultures are repeated throughout the period of fever. It is necessary to determine the sensitivity of the detected microorganisms to antibiotics. Despite the prevalence of intestinal microflora ( Escherichia coli , anaerobic streptococci), it is necessary to look for other, unusual strains ( Pseudomonas spp .). When carrying out ERCPH, you should take bile for sowing.

On the survey radiographs of the abdominal cavity, you can see gallstones or gallstones of the common bile duct, which are located more medially and posteriorly from the projection of the gallbladder.

Ultrasound may reveal an enlargement of intrahepatic bile ducts, although they are often not enlarged. Stones of the terminal section of the common bile duct can be detected with the help of ultrasound.

The presence of stones is confirmed by cholangiography (preferably endoscopic).

Diagnosis

The diagnosis is usually easy if the jaundice was preceded by hepatic colic and fever. However, clinical variants with indistinct dyspepsia are often encountered, but without painfulness of the gallbladder, fever, changes in the leukocyte formula, or jaundice (sometimes itching), but without pain. In these cases, differential diagnosis is performed with other forms of cholestasis (including cholestasis due to the tumor) and acute viral hepatitis. With tumor obstruction of the bile duct, infection of bile and cholangitis is rare and usually develops after endoscopic cholangiography or stenting.

Unsuccessful stones of common bile duct

Approximately 5-10% of patients with cholecystectomy with revision of the common bile duct can not remove all stones. Most often, the stones of intrahepatic bile ducts remain undetected during surgery. The pain that occurs when the T-shaped drainage is clamped allows one to suspect the presence of stones in the bile ducts, which look like cholangiograms as filling defects. In the postoperative period, sepsis and cholangitis may develop, but in most cases, undeveloped gallstones stones do not appear for many years.

Therapeutic tactics depend on the clinical picture, the age and general condition of the patient, the equipment of the medical facility and the availability of qualified personnel. The purpose of antibiotics is more focused on the treatment and prevention of septicemia than on the sterilization of bile, and with unresolved obturation of the common bile duct it is possible to achieve only a temporary effect. It is necessary to drain the common bile duct, correct vodnoelektrolitnye violations, in the presence of jaundice intramuscularly administer vitamin K.

Acute purulent obturation cholangitis

Clinical manifestations of this syndrome are fever, jaundice, pain, confusion and arterial hypotension (Reynold's pentada). Later, renal insufficiency develops and as a consequence of DIC-syndrome - thrombocytopenia. The condition requires urgent medical intervention.

Laboratory tests include blood cultures, determination of the number of leukocytes and platelets, prothrombin time and renal function. When ultrasound reveals the expansion of the biliary tract, which can contain stones. Even with negative results of ultrasound, endoscopic cholangiography should be performed if the symptomatology indicates a pathology of biliary tract.

Treatment consists in the appointment of antibiotics of a wide spectrum of action, emergency decompression of the biliary tract and massive infusion therapy. In calculating the Gram-negative intestinal microflora, it is advisable to combine aminoglycosides (gentamicin or netilmicin) with ureidopenicillins (piperacillin or azlocillin) and metronidazole (for anaerobes). In the presence of stones in the common bile duct, with which the majority of cases are associated, produce ERCP with papillosphincterotomy and removal of the stone, if this is not hampered by the structure of the biliary tract and the state of the coagulation system. When you can not remove the stone, leave the nasobiliary drainage.

The surgeon must ensure the decompression of the bile ducts by any method available to him. Currently, the method of choice is endoscopic decompression, although it is associated with a significant lethality (5-10%). If endoscopic decompression is not possible, resort to percutaneous transhepatic drainage of the biliary tract. With "open" drainage, mortality is significantly higher than with minimally invasive, and is 16-40%. Typically, after decompression, septicemia and toxemia quickly disappear. If this does not happen, you need to check the patency of the drainage, as well as exclude other causes of sepsis, such as empyema of the gallbladder and liver abscess.

Treatment with antibiotics continues for a week, which is especially important for gallstones, as cholangitis can be complicated by the empyema of the gallbladder.

Such interventions as cholangiography without drainage or endoprosthetics of the stenotic area can lead to the development of purulent cholangitis against the background of tumor stricture of the common bile duct. Therapeutic tactics in these complications also consists in prescribing antibiotics and decompressing the biliary tract.

Acute cholangitis

Symptoms of acute cholangitis:

Malaise and fever are replaced by chills with profuse sweating (alternating biliary fever Charcot). Some components of the triad of Charcot (fever, pain, jaundice) may be absent. The laboratory study includes the determination of the number of leukocytes, indicators of kidney function, liver and blood cultures. With ultrasound, you can identify the defeat of biliary tract.

The choice of antibiotics depends on the patient's condition and the facilities of the medical institution. Usually it is enough to appoint ampicillin, ciprofloxacin or a preparation of cephalosporin series. The timing of the cholangiography is determined based on the response to antibiotics and the patient's condition. Removal of stones is performed after endoscopic sphincterotomy. If you can not remove the stones, provide an outflow of bile through the nasopharyngeal drainage or an endoprosthesis, regardless of whether the gallbladder has been removed or not. Questions relating to cholecystectomy are discussed below.

With the help of multifactor analysis, in a mixed group of patients who underwent surgical and minimally invasive treatment, signs were found that were associated with an unfavorable outcome of cholangitis: acute renal failure, concomitant abscess or cirrhosis, cholangitis against a high tumor stenosis of the biliary tract or after percutaneous transhepatic cholangiography CHCHKH), cholangitis in women and age over 50 years.

Choledocholithiasis without cholangitis

With choledocholithiasis without cholangitis, planned endoscopic cholangiography, papillosphincterotomy, stone removal and prophylactic antibiotics are shown. The stone can be removed without resorting to papillosphincterotomy, most often with balloon dilation of the sphincter. In 4-10% of cases, pancreatitis develops. The results of randomized trials are expected, which so far indicate the inadvisability of papillosphincterotomy.

Gallstone disease and acute pancreatitis

Getting into the vater of an ampoule, the stones of the common bile duct can cause acute pancreatitis. They rarely reach large sizes and usually pass into the duodenum, after which the inflammation subsides. If the stones are infringed in the papilla, the symptoms of pancreatitis increase. Pancreatitis associated with gallstones is diagnosed by changes in functional liver samples, especially to increase transaminase activity and ultrasound. It was shown that early ERCP and papillosphincterotomy with stone removal reduce the number of cholangitis and other complications in patients with severe pancreatitis. Questions about the timing of this intervention and the selection of patients need further study.

A yellow putty can also cause an attack of acute pancreatitis.

Large stones of common bile duct

After papillosphincterotomy, stones larger than 15 mm in diameter can be difficult or impossible to remove with a standard basket or balloon catheter. And although the individual stones depart independently, the surgeon can apply this or that alternative technique depending on his skills and preferences.

You can destroy the stone mechanically, but the possibility of removing fragments depends on their size and shape, as well as the design of the basket. With new models of baskets, mechanical lithotripsy is successful in 90% of cases.

The simplest method, especially in high-risk patients, is the introduction of a permanent or temporary (for decompression before an "open" or endoscopic revision of the common bile duct) of the endoprosthesis. Early complications are observed in 12% of cases, lethality is 4%. Late complications include biliary colic, cholangitis and cholecystitis.

Extracorporeal shock wave lithotripsy can destroy 70-90% of the large stones of the common bile duct, after which in most patients, concrements are evacuated through the sphincterotomy hole. Mortality in the first 30 days after the procedure does not exceed 1%.

The stones can be dissolved with methyl butyl ether, although the introduction of the drug through a nasobiliary probe is associated with certain technical difficulties.

Electro-hydraulic and laser lithotripsy through the endoscope are under development.

Removal of stones through the channel of the T-shaped drainage

Through the channel of the T-shaped drainage tube, stones can be removed in 77-96% of patients. In 2-4% of cases, manipulation is complicated by cholangitis, pancreatitis, rupture of the canal. The T-shaped tube after the operation should be left for 4-5 weeks, so that around it formed a fibrous channel. This method of removing stones is in addition to endoscopic papillosphincterotomy and increases its effectiveness to 75%. In elderly patients, as well as with intolerance to T-shaped drainage, insufficient diameter or unfavorable direction of his canal, an endoscopic technique is chosen.

Intrahepatic stones

Stones of the intrahepatic ducts are particularly common in some regions, for example in Brazil and the Far East, where they are caused by parasitic infestations. Also, the stones are formed with chronic obstruction of the biliary tract due to the stricture of the biliodigestive anastomosis, primary sclerosing cholangitis or Caroli disease and are referred to as brown pigment stones. The addition of secondary infection leads to the formation of multiple liver abscesses.

Percutaneous transhepatic injection of large diameter catheters, if necessary in combination with an "open" operation, allows the removal of stones in 90% of patients, which in most cases leads to the disappearance of symptoms. Percutaneous transhepatic cholangioscopy allows the removal of stones of the intrahepatic ducts in more than 80% of patients. In 50% of patients with strictures of bile ducts, stones recur.

Mirizi's syndrome

Infringement of the stone in the bladder duct or neck of the gallbladder can lead to partial obturation of the common hepatic duct, which leads to the development of recurrent cholangitis. Due to a bedsore, a message can be formed with the common hepatic duct.

The condition is diagnosed with endoscopic or percutaneous cholangiography. When ultrasound is determined by the stones outside the hepatic duct. Treatment consists in removing the gallbladder, bladder duct and stones.

Hemobiology

Bleeding to the biliary tract can develop after an operation and puncture liver biopsy, as a complication of the aneurysm of the hepatic artery or its branches, extra- and intrahepatic bile duct tumors, cholelithiasis, helminthic invasion and liver abscess, rarely varicose-dilated veins in portal hypertension and sometimes with primary liver cancer. Currently, 40% of cases of hemobiology are of iatrogenic nature (after liver biopsy, percutaneous transhepatic cholangiography - CHCHHG and bile drainage).

There are pains caused by the passage of the biliary tract clots, jaundice, bloody vomiting and melena. A small amount of bleeding can reveal an analysis of feces for latent blood.

The combination of gastrointestinal bleeding with bile colic, jaundice, soreness or palpable formation in the upper right quadrant of the abdomen makes one think of hemobiology.

With ERCPH or CHCHHG can be determined clots in the bile ducts. Often hemorrhoid stops on its own, in other cases embolization under the control of angiography is shown. If bleeding and biliary colic attacks do not stop, an "open" revision and drainage of the common bile duct may be required.

[1], [2], [3], [4], [5], [6]