Choledocholithiasis- obstructive jaundice

OBSTRUCTIVE JAUNDICE
Dr.B.Selvaraj MS;Mch;FICS;
Professor Of Surgery
Melaka Manipal Medical college
Melaka 75150 Malaysia
CHOLEDOCHOLITHIASIS

Choledocholithiasis- Overview
Causes of obstructive jaundice
Classical clinical vignette
Etiopathogenesis
Clinical features & complications
Investigations
Treatment
Mindmap of Choledocholithiasis
Diagnostic Algorithm in obstructive jaundice
Management algorithm in choledocholithiasis

Obstructive Jaundice- Causes
• Intraluminal causes:
- Choledocholithiasis
- Clonorchis sinensis
- Ascariasis & Schitosomiasis
• Mural causes:
- Malignant stricture-cholangiocarcinoma
- Benign stricture- Scelerosing cholangitis
• Extrinsic Causes:
- Ca Head of Pancreas
- Periampullary Carcinoma, Portal LN

Classical Clinical
Vignette
A 40-year-old female presents with a 24 hour history of right upper
quadrant (RUQ) and epigastric pain, associated with nausea and
vomiting. She has had similar pain in the past, particularly after
eating fatty foods. According to her family, over the last few hours,
the patient has become slightly confused. Past medical history is
negative.
O/E: She is moderately tender in the RUQ to deep palpation. She has
slight scleral icterus. She has noted dark- coloured urine. The
remainder of her abdominal exam is negative.
 Vitals: BP-90/60 mms of Hg; PR-110/mt; RR-16/mt;T:102*F

Classical Clinical Vignette
Laboratory examination:
 TWBC- 15,000/μL(4 to 11,000/μL),
 Total bilirubin-4mgm/dl(0.1 to 1.2mgm/dl) Direct bili- 3mgm/dl
 ALP- 350μ/L (33-131μ/L); GGT- 330μ/L (8-88μ/L)
 AST- 300μ/L(5-35μ/L); ALT- 280μ/L(7-56μ/L)
 Sr Amylase- 100μ/L( 30-110μ/L)
Urine is positive for bilirubin
CHOLEDOCHOLITHIASIS
WITH CHOLANGITIS

Choledocholithiasis-Etiology
It is stones in the CBD and biliary tree.
Primary—Rare 5%—brown pigment stones. They are formed in
CBD and biliary tree itself, and are multiple, often sludge like,
commonly pigment or mixed type, extends into hepatic ducts.
Causes: Biliary stasis, biliary dyskinesia, caroli’s disease,
choledochal cyst, clonorchiasis, ascariasis Etc
Secondary—Common 95%—black pigment stones/cholesterol
stones. It is seen in 15% of gallstone disease; 75% are cholesterol
stones, 25% are pigment stones.

Clinical Features
50% asymptomatic
Biliary colic because of CBD obstruction by stone-
pain in RHC & epigastrium
 Intermittent chills, fever, or jaundice
accompanies biliary colic Charcot’s triad
Ascending cholangitis
 Suppurative cholangitis Reynold’s pentad
Persistent pain, fever, jaundice, shock & AMS
 Painful jaundice with dark color urine, clay
colored stool and pururitus.
Features of Ac Pancreatitis in distal CBD stone
impaction

Clinical Features
 Patient may be icteric and toxic, with high fever and chills, or may
appear to be perfectly healthy.
A palpable gallbladder is unusual in patients with obstructive
jaundice from common duct stone because the obstruction is
transient and partial, and scarring of the gallbladder renders it
inelastic and non distensible.
Courvoisier’s Law: “ In a jaundiced patient if GB is palpably
enlarged it is not due to Gall stone”
Tenderness in the right upper quadrant is not often as marked as in
acute cholecystitis, DU perforation or Ac Pancreatitis
 Tender enlarged liver +

Differential diagnosis
Obstructive jaundice due to other causes:
Carcinoma of head of pancreas
 Periampullary carcinoma
Carcinoma of biliary tree- cholangiocarcinoma
Biliary stricture- Scelerosing cholangitis
Intrahepatic cholestasis from drugs, pregnancy, chronic active
hepatitis, or primary biliary cirrhosis may be difficult to distinguish
from extrahepatic obstruction. ERCP would be appropriate to make
the distinction.

COMPLICATIONS
 Liver dysfunction and biliary
cirrhosis.
 White bile formation and liver
failure.
 Suppurative cholangitis.
Liver abscess.
 Septicaemia.
 Pancreatitis if CBD stone is near
sphincter of Oddi blocking drainage of
bile and pancreatic duct.

Investigations- Labs
 In cholangitis, leukocytosis of 15,000/mL is usual, and values above
20,000/mL are common.
T bilirubin level usually remains under 10 mg/dL, and most are in
the range of 2-4 mg/dL. The direct fraction exceeds the indirect, but
the latter becomes elevated in most cases.
Bilirubin levels do not ordinarily reach the high values seen in
malignant tumors because the obstruction is usually incomplete and
transient. In fact, fluctuating jaundice is so characteristic of
choledocholithiasis.
Serum alkaline phosphatase & GGT levels usually rises
Mild increases in AST and ALT are often seen

Investigations-Imaging
 AXR & USG abdomen- ineffective to pick up CBD stones
 USG abdomen may indicate dilated CBD >1cm
 CECT- can pick up CBD stone
 MRCP- best non-invasive diagnostic investigation
 ERCP- Gold standard- diagnostic & therapeutic
 EUS- can pick up CBD stone and can take biopsy if there is a mass

Investigations-Imaging
ERCP MRCP

TREATMENT
 In absence of cholangitis:
ERCP, Sphincterotomy, CBD stone removal by dormia basket or
balloon followed by Lap cholecystectomy.
Lap cholecystectomy with Lap CBD exploration
 In presence of cholangitis:
ERCP with sphincterotomy and stone extraction or stent placement-
decompression
 PTBD- Percutaneous transhepatic biliary drainage in ERCP failed
cases
Surgical treatment: Only when above two procedures not possible.
Decompression of CBD with T tube.

TREATMENT
 Open cholecystectomy, intra op cholangiogram, choledocholithotomy
with T tube placement.
 Remove T tube—10 to 14 days after T tube cholangiogram
Missed/retained/residual stones (< 2 years):
If T tube present Percutaneous stone extraction via T tube tract
after 4-6 weeks (Burhenne technique) using choledochoscope
If T tube absent ERCP stone removal
Recurrent stones (> 2 years):
ERCP—first approach
If duct dilated > 2 cm—choledochoduodenostomy or transduodenal
sphincteroplasty

Cholelithiasis Vs Choledocholithiasis

Obstructive Jaundice- Diagnostic Algorithm

Choledocholithiasis Treatement Algorithm

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