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

In most cases, common bile duct stones migrate from the gallbladder and are associated with calculous cholecystitis. The migration process depends on the ratio of the stone size and the lumen of the cystic and common bile ducts. An increase in the size of the stone in the common bile duct causes obstruction of the latter and promotes the migration of new stones from the gallbladder.

Secondary stones (not formed in the gallbladder) are usually associated with partial obstruction of the bile ducts due to an unremoved stone, traumatic stricture, sclerosing cholangitis, or congenital anomalies of the bile ducts. An infection may be the trigger for stone formation. Stones are brown in color, may be single or multiple, have an oval shape, and are oriented along the axis of the duct. They are usually trapped in the hepatopancreatic (Vater's) ampulla.

Changes in choledocholithiasis

Due to the valve effect, obstruction of the terminal part of the common bile duct by a stone is usually partial and transient. In the absence of jaundice, the histological picture in the liver is unchanged; jaundice is accompanied by signs of cholestasis. In chronic choledocholithiasis, concentric scarring of the bile ducts is found, and secondary sclerosing cholangitis and biliary cirrhosis Cholangitis eventually develop. Stagnation of bile promotes its infection, in particular by intestinal microflora, while the bile becomes turbid, dark brown (bile putty), in rare cases - purulent. The common bile duct is dilated, its walls are thickened, sloughing and ulceration of the mucous membrane are noted, especially in the hepatopancreatic ampulla. Cholangitis can spread to the intrahepatic bile ducts and, in severe, long-term infections, leads to the formation of liver abscesses, which on section appear as cavities filled with pus and bile and communicating with the bile ducts. Escherichia is the most common bacterium isolated from cholangitis.coli, less commonly - Klebsiellaspp., Streptococcusspp.. Bacteroidesspp., Clostridiaspp.

Strangulation or passage of stones through the ampulla of Vater can cause acute or chronic pancreatitis.

Clinical syndromes

Choledocholithiasis may be asymptomatic and detected only by imaging studies during cholecystectomy for chronic calculous cholecystitis. In other cases, choledocholithiasis is complicated by acute cholangitis with jaundice, pain, and fever. In older people, the disease may manifest itself only as mental and physical exhaustion. Unremoved common bile duct stones cause clinical signs early or late after surgery or remain "silent."

Cholangitis with jaundice

The classic clinical picture is characterized by the appearance of jaundice, abdominal pain, chills and fever in elderly women with obesity and a history of epigastric pain, flatulence, dyspepsia, intolerance to fatty foods. Cholestatic jaundice does not develop in all patients, it can be mild or intense. Complete obstruction of the common bile duct is rare, which is associated with fluctuations in the level of bile pigments in the feces.

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

Bile cultures show an increase in mixed intestinal microflora, predominantly Escherichiacoli.

The activity of alkaline phosphatase, GGT and the level of conjugated bilirubin in the serum increase, which is characteristic of cholestasis. In acute obstruction, a short-term significant increase in transaminase activity may be observed.

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

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

Blood cultures are repeated throughout the fever period. It is necessary to determine the sensitivity of the identified microorganisms to antibiotics. Despite the predominance of intestinal microflora in the cultures (Escherichiacoli, anaerobic streptococci), it is necessary to specifically search for other, unusual strains (Pseudomonasspp.). When performing ERCP, bile should be taken for culture.

Plain abdominal radiographs may show gallbladder stones or common bile duct stones that are located more medially and posterior to the projection of the gallbladder.

Ultrasound may reveal dilation of the intrahepatic bile ducts, although they are usually not dilated. Terminal common bile duct stones are often impossible to detect with ultrasound.

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

Diagnosis

The diagnosis is usually easy if jaundice was preceded by hepatic colic and fever. However, clinical variants with vaguely expressed dyspepsia but without gallbladder tenderness, fever, changes in the white blood cell count, or with jaundice (sometimes itching) but without pain are common. In these cases, differential diagnosis is made with other forms of cholestasis (including cholestasis caused by a tumor) and acute viral hepatitis. In case of tumor obstruction of the bile duct, infection of the bile and cholangitis are rare and usually develop after endoscopic cholangiography or stenting.

Unremoved common bile duct stones

In approximately 5-10% of patients, cholecystectomy with revision of the common bile duct fails to remove all stones. More often than others, stones in the intrahepatic bile ducts remain unnoticed during surgery. Pain that occurs when clamping the T-shaped drainage allows one to suspect the presence of stones in the bile ducts, which look like filling defects on cholangiograms. Sepsis and cholangitis may develop in the postoperative period, but in most cases, unremoved stones in the bile ducts do not manifest themselves for many years.

Treatment tactics depend on the clinical picture, age and general condition of the patient, the equipment of the medical institution and the availability of qualified personnel. The prescription of antibiotics is aimed more at treating and preventing septicemia than at sterilizing bile, and in the case of unresolved obstruction of the common bile duct, it allows achieving only a temporary effect. It is necessary to drain the common bile duct, correct water-electrolyte imbalances, and in the presence of jaundice, administer vitamin K intramuscularly.

Acute purulent obstructive cholangitis

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

Laboratory tests include blood cultures, white blood cell and platelet counts, prothrombin time, and renal function tests. Ultrasound reveals dilation of the bile ducts, which may contain stones. Even if the ultrasound results are negative , endoscopic cholangiography should be performed if the symptoms indicate bile duct pathology.

Treatment consists of broad-spectrum antibiotics, emergency decompression of the bile ducts, and massive infusion therapy. In the case of 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, which are associated with most cases of the disease, ERCP is performed with papillosphincterotomy and removal of the stone, unless the structure of the bile ducts and the state of the coagulation system prevent this. When it is not possible to remove the stone, nasobiliary drainage is left.

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

Antibiotic treatment is continued for a week, which is especially important for gallstones, since cholangitis can be complicated by 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. The treatment tactics for these complications also include the administration of antibiotics and decompression of the bile ducts.

Acute cholangitis

Symptoms of acute cholangitis:

Malaise and fever are followed by chills with profuse sweating (intermittent biliary fever of Charcot). Some components of the Charcot triad (fever, pain, jaundice) may be absent. Laboratory examination includes determination of the number of leukocytes, indicators of kidney and liver function, and blood cultures. Ultrasound can reveal damage to the bile ducts.

The choice of antibiotics depends on the patient's condition and the guidelines of the medical institution. Ampicillin, ciprofloxacin, or a cephalosporin are usually sufficient. The timing of cholangiography is determined based on the response to antibiotics and the patient's condition. Stones are removed after endoscopic sphincterotomy. If stones cannot be removed, bile is drained through a nasobiliary drain or endoprosthesis, regardless of whether the gallbladder has been removed. Issues related to cholecystectomy are discussed below.

Using multivariate analysis in a mixed group of patients who underwent surgical and minimally invasive treatment, features associated with an unfavorable outcome of cholangitis were identified: acute renal failure, concomitant liver abscess or cirrhosis, cholangitis in the presence of high tumor stenosis of the biliary tract or after percutaneous transhepatic cholangiography (PTC), cholangitis in women and age over 50 years.

Choledocholithiasis without cholangitis

In choledocholithiasis without cholangitis, planned endoscopic cholangiography, papillosphincterotomy, stone removal, and prophylactic antibiotics are indicated. The stone can be removed without papillosphincterotomy, most often using balloon dilation of the sphincter. Pancreatitis develops in 4-10% of cases. Results of randomized trials are awaited, which so far indicate that papillosphincterotomy is inappropriate.

Gallstone disease and acute pancreatitis

Gallstones in the common bile duct may cause acute pancreatitis if they enter the ampulla of Vater. They rarely reach large sizes and usually pass into the duodenum, after which the inflammation subsides. If the stones become trapped in the papilla, the symptoms of pancreatitis increase. Gallstone-associated pancreatitis is diagnosed by changes in liver function tests, especially by increased transaminase activity, and by ultrasound. Early ERCP and papillosphincterotomy with stone removal have been shown to reduce the incidence of cholangitis and other complications in patients with severe pancreatitis. The timing of this intervention and patient selection require further study.

Bile sludge can also cause an attack of acute pancreatitis.

Large stones of the common bile duct

After papillosphincterotomy, stones larger than 15 mm in diameter may be difficult or impossible to remove using a standard basket or balloon catheter. Although some stones may pass on their own, the surgeon may use one or another alternative technique depending on his or her skills and preferences.

It is possible to break the stone mechanically, but the ability to remove fragments depends on their size and shape, as well as the basket design. With new basket models, mechanical lithotripsy is successful in 90% of cases.

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

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

Stones can be dissolved with methylbutyl ether, although administration of the drug through a nasobiliary tube is associated with certain technical difficulties.

Electrohydraulic and laser lithotripsy via an endoscope are under development.

Removal of stones through a T-shaped drainage channel

Stones can be removed through the channel of the T-shaped drainage tube in 77-96% of patients. In 2-4% of cases, the manipulation is complicated by cholangitis, pancreatitis, and channel rupture. The T-shaped tube should be left in place for 4-5 weeks after surgery so that a fibrous channel can form around it. This method of stone removal is an addition to endoscopic papillosphincterotomy and increases its efficiency to 75%. In elderly patients, as well as in cases of intolerance to the T-shaped drainage, insufficient diameter, or unfavorable direction of its channel, an endoscopic method is chosen.

Intrahepatic stones

Intrahepatic duct stones are particularly common in some regions, such as Brazil and the Far East, where they are caused by parasitic infestations. They also form in chronic biliary obstruction due to biliodigestive anastomosis stricture, primary sclerosing cholangitis or Caroli's disease and are a type of brown pigment stones. The addition of a secondary infection leads to the formation of multiple liver abscesses.

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

Mirizi syndrome

A stone in the cystic duct or the neck of the gallbladder may cause partial obstruction of the common hepatic duct, which leads to the development of recurrent cholangitis. A pressure ulcer may form a connection with the common hepatic duct.

The condition is diagnosed by endoscopic or percutaneous cholangiography. Ultrasound reveals stones outside the hepatic duct. Treatment involves removing the gallbladder, cystic duct, and stones.

Hemobilia

Bleeding into the bile ducts may develop after surgical and puncture liver biopsy, as a complication of aneurysm of the hepatic artery or its branches, extra- and intrahepatic tumors of the bile ducts, cholelithiasis, helminthic invasion and liver abscess, rarely - varicose veins in portal hypertension and sometimes in primary liver cancer. Currently, 40% of cases of hemobilia are iatrogenic (after liver biopsy, percutaneous transhepatic cholangiography - PTC and bile drainage).

Pain caused by the passage of clots through the bile ducts, jaundice, bloody vomiting and melena are noted. Small amounts of bleeding can be detected by a stool test for occult blood.

The combination of gastrointestinal bleeding with biliary colic, jaundice, tenderness or a palpable mass in the right upper quadrant of the abdomen suggests hemobilia.

ERCPG or PTC may show clots in the bile ducts. Hemobilia often resolves spontaneously, but in other cases angiographically guided embolization is indicated. If bleeding and biliary colic attacks do not stop, an "open" exploration and drainage of the common bile duct may be required.

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