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PubMed1990

Choledocholithiasis in infants: diagnostic and therapeutic problems.

During the 3-year period, January 1986 through December 1988, 7 of 24 infants evaluated for cholestatic liver disease were found to have choledocholithiasis with or without associated gallbladder disease. Five were born prematurely with associated predisposing factors, especially systemic infection and total parenteral nutrition. The clinical course varied from spontaneous recovery in two patients to ongoing liver disease requiring surgical or endoscopic intervention in five infants. Asymptomatic patients with normal liver function and persistently dilated extrahepatic biliary trees posed the most difficult therapeutic problems. Endoscopic retrograde cholangiography appeared to be an effective and rewarding therapeutic approach.

Biliary Tract↗

PubMed1993

Anorexia and weight loss as the solitary symptoms of choledocholithiasis.

Two patients are described who presented symptoms of anorexia and weight loss. Further investigation revealed choledocholithiasis in both cases, though neither patient had the classic symptoms of biliary colic, jaundice, cholangitis, or pancreatitis. The associated weight loss and anorexia resolved completely after successful bile duct surgery. These cases emphasize the need to exclude benign causes of common bile duct obstruction in patients with anorexia, weight loss, and abnormal results of liver function tests, mimicking a possible underlying malignancy.

Aged↗

PubMed2003

Cholelithiasis and choledocholithiasis after sequential cytarabine and asparaginase.

We report 2 children with acute leukemia who developed symptomatic cholelithiasis and choledocholithiasis shortly after receiving sequential high-dose cytarabine and asparaginase. Known risk factors for gallstone formation were not present in our patients. These children did not experience any unusual therapy-related hepatic toxicity after laparoscopic cholecystectomy.

Antimetabolites, Antineoplastic↗

PubMed1986

Atrophy and ductopenia of the right hepatic lobe in a patient with choledocholithiasis.

An extremely rare case of atrophy and extensive ductopenia of the right hepatic lobe is presented. The surgically resected atrophic right lobe (100 g) did not show cholestasis or cirrhosis. The right hepatic bile duct revealed sclerosis with luminal obliteration and marked diminution of its branches. The extrahepatic bile duct contained a single cholesterol stone. The right portal vein branches showed luminal narrowing. Disturbance of biliary drainage following sclerosing cholangitis and impediment of portal venous flow in the right hepatic lobe were considered responsible for atrophy of the lobe. Although choledocholithiasis presumably played an important part in the pathogenesis of the sclerosing cholangitis and ductopenia, the reason for selective involvement of the right biliary tree remains nuclear.

Aged↗

PubMed1989

Common duct exploration or endoscopic sphincterotomy for choledocholithiasis?

The relative indications for operative common duct exploration (CDE) and endoscopic sphincterotomy (ES) in treating common duct stones are often unclear. This prospective study compared CDE and ES in treating choledocholithiasis after excluding patients with acute cholecystitis, idiopathic pancreatitis, sphincter of Oddi dysfunction and malignant disease. One hundred and two patients had 105 CDE and a further 50 patients had 57 ES. Of the patients having CDE, 76 also had cholecystectomy for gall-bladder (GB) disease while 26 had prior cholecystectomy. With ES, in 16 the GB was present and not removed while 34 patients had had prior cholecystectomy. Hospitalization was significantly less following ES. There was one peri-operative death after CDE and none after ES. There were two late biliary-related deaths, 3 and 27 months after ES, in patients who developed acute cholecystitis. In post-cholecystectomy patients having ES, complications were fewer and less severe after ES (15%) than CDE (41%). In patients with an intact GB, peri-operative complications occurred in 30% after cholecystectomy and CDE. Following ES alone, complications occurred in 33% with the majority of these complications arising from the diseased GB. It is concluded that the optimal treatment for post-cholecystectomy patients with bile-duct stones is ES. In elderly patients with an intact GB, the bile-duct stones can be treated by ES; whether subsequent cholecystectomy is necessary should be assessed on the likelihood of future GB complications.

Adult↗

PubMed1993

Left lateral laparoscopic cholecystectomy and its relevance to choledocholithiasis.

One of the current challenges to the laparoscopic biliary surgeon is the management of bile duct stones. While laparoscopic bile duct exploration is in its infancy, pre- and postoperative endoscopic retrograde cholangiopancreatography with or without endoscopic papillotomy (ERCP/EP) currently plays a significant role. Intra-operative ERCP/EP has advantages over pre- and postoperative ERCP/EP; however it has not gained popularity due, partly, to the difficulties associated with ERCP/EP being performed with the patient in the supine position. This study prospectively assessed, in 10 consecutive patients, the feasibility of performing laparoscopic cholecystectomies in the left lateral position, a position amenable to intra-operative ERCP/EP if necessary. It is concluded that laparoscopic cholecystectomy in the left lateral position can be performed safely, with similar ease and results as in the supine position, increasing the options available to manage choledocholithiasis.

Adult↗

PubMed1997

Prediction of recurrent choledocholithiasis by quantitative cholescintigraphy in patients after endoscopic sphincterotomy.

BACKGROUND: Endoscopic sphincterotomy (EST) is widely used for the removal of stones from the bile duct, but stones recur in about one fifth of patients. AIMS: To investigate hepatic clearance by quantitative cholescintigraphy (QC) in patients after EST and to discern the relationship between biliary emptying and stone recurrence. METHODS: One hundred and forty nine patients who had EST and clearance of the bile duct for choledocholithiasis were selected. All patients were confirmed to have complete EST by sphincter of Oddi manometry and underwent QC soon after normalisation of liver function. Regular clinical follow up was performed for each patient. RESULTS: During a mean 36 month follow up, 22 (14.8%) patients developed recurrent stones in the bile duct. Irrespective of the status of the gall bladder, patients with recurrent stones had a slower hepatic clearance of radioisotope during QC compared with patients without stone recurrence, but only the differences in cholecystectomised patients had statistical significance. After carrying out multivariate analysis, one parameter of QC, percentage clearance of maximal count at 45 minutes, was found to be the only significant factor for stone recurrence. All recurrent stones in the common bile duct were successfully removed at endoscopy. CONCLUSION: Slower hepatic clearance as shown by QC is an important factor responsible for stone recurrence after sphincter ablation.

Adult↗

PubMed1999

Use of magnetic resonance cholangiography in the diagnosis of choledocholithiasis: prospective comparison with a reference imaging method.

BACKGROUND: Magnetic resonance cholangiography (MRC) is a new technique for non-invasive imaging of the biliary tract. AIM: To assess the results of MRC in patients with suspected bile duct stones as compared with those obtained with reference imaging methods. PATIENTS/METHODS: 70 patients (34 men and 36 women, mean (SD) age 71 (15.5) years; median 75) with suspected bile duct stones were included (cholangitis, 33; pancreatitis, three; suspected post-cholecystectomy choledocholithiasis, nine; cholestasis, six; stones suspected on ultrasound or computed tomography scan, 19). MR cholangiograms with two dimensional turbo spin echo sequences were acquired. Endoscopic retrograde cholangiography with or without sphincterotomy (n = 63), endosonography (n = 5), or intraoperative cholangiography (n = 2) were the reference imaging techniques used for the study and were performed within 12 hours of MRC. Radiologists were blinded to the results of endoscopic retrograde cholangiography and previous investigations. RESULTS: 49 patients (70%) had bile duct stones on reference imaging (common bile duct, 44, six of which impacted in the papilla; intrahepatic, four; cystic duct stump, one). Stone size ranged from 1 to 20 mm (mean 6.1, median 5.5). Twenty seven patients (55%) had bile duct stones smaller than 6 mm. MRC diagnostic accuracy for bile duct lithiasis was: sensitivity, 57.1%; specificity, 100%; positive predictive value, 100%; negative predictive value, 50%. CONCLUSIONS: Stones smaller than 6 mm are still often missed by MRC when standard equipment is used. The general introduction of new technical improvements is needed before this method can be considered reliable for the diagnosis of bile duct stones.

Adult↗

PubMed1987

Choledocholithiasis: treatment with extracorporeal shock wave lithotripsy.

In a patient with choledocholithiasis, a duodenal diverticulum precluded endoscopic retrograde bile duct cannulation. A transhepatic catheter was used to opacify the bile ducts and to guide the endoscopic sphincterotome into the major duodenal papilla. Because limited sphincterotomy did not allow extraction or spontaneous passage of the common duct stones, extracorporeal lithotripsy was performed. Following fragmentation, the stones passed spontaneously and without complications.

Aged↗

PubMed1995

Bile duct obstruction and choledocholithiasis: diagnosis with MR cholangiography.

PURPOSE: To evaluate the accuracy of magnetic resonance (MR) cholangiopancreatography in the diagnosis of bile duct obstruction. MATERIALS AND METHODS: One hundred twenty-six patients with clinically suspected bile duct obstruction underwent MR cholangiopancreatography with heavily T2-weighted fast spin-echo sequences. Reviewers were blinded to clinical and imaging findings. RESULTS: Seventy-nine patients had biliary obstruction that was diagnosed with MR cholangiopancreatography in 72 patients for a sensitivity of 91%, specificity of 100%, and overall accuracy of 94%. Thirty-two patients had choledocholithiasis that was diagnosed with MR cholangiopancreatography in 26 patients for an accuracy of 94%, sensitivity of 81%, specificity of 98%, positive predictive value of 93%, and negative predictive value of 94%. Fourteen patients had malignant obstruction that was diagnosed with MR cholangiopancreatography in 12 patients for a sensitivity and a positive predictive value of 86%, specificity and negative predictive value of 98%, and accuracy of 97%. CONCLUSION: MR cholangiopancreatography is a noninvasive technique with excellent accuracy in the diagnosis of bile duct obstruction and its causes.

Adolescent↗

PubMed1999

Must ERCP Be routinely performed if choledocholithiasis is suspected?

OBJECTIVE: To evaluate the results of preoperative endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis and treatment of those patients suspected of harboring bile duct stones before laparoscopic cholecystectomy (LC). PATIENTS AND METHODS: A total of 1,235 consecutive LCs performed between 1991 and 1997 were studied prospectively. ERCP was performed to explore the common bile duct (CBD) preoperatively when choledocholithiasis was suspected on the basis of clinical, analytical or echographical data. RESULTS: ERCPs were performed in 268 patients: unsuccessful CBD evaluation in 3%; dilated CBD without lithiasis in 13%, and normal exploration in 37% (99 patients). CBD stones were found in 46% (124 patients), and endoscopic sphincterotomy was then performed and stone extraction attempted. Endoscopic therapy achieved 92.8% successful removal of CBD stones (115 patients). There was no ERCP-related mortality and the morbidity rate was 6%. Retained CBD stones have been observed in 7 cases after ERCP-LC; all of them have been successfully treated by ERCP. CONCLUSIONS: A combined approach to bile duct stones with selective use of ERCP followed by LC is a good therapeutical alternative. Nevertheless, the usual selection criteria for ERCP may lead to unnecessary exploration. It appears to be necessary to modify the current diagnostic and therapeutic strategy.

Cholangiopancreatography, Endoscopic Retrograde↗

PubMed1981

Follow-up studies of surgical treatment for choledocholithiasis.

The follow-up results of cholecystectomy and common duct exploration with T-tube drainage for 308 patients with common bile duct stones were studied. Nine patients evaluated as "poor" included seven with residual stones and two with recurrent stones.. Cholangiography at the time of follow-up manifested the evidence of a statistically significant reduction of the bile-duct diameter compared with the preoperative level in both cholesterol and calcium bilirubinate cases. The reduction was particularly conspicuous in the group with marked dilatation of the bile duct, regardless of the types of stone. Of the 134 patients with cholelithiasis who underwent reoperations in our Department, 75 (87%) belonged to residual, 11 (13%) to recurrent group. Of the 11 patients with recurrent stones, nine had obvious causes for stone recurrence such as bile-duct stenosis or stricture at the anastomotic site. These results suggest that without existence of evident stenosis at the papilla of Vater or in the lower bile duct, patients with choledocholithiasis, regardless of types of stone, could be curable effectively only by cholecystectomy and choledocholithotomy with T-tube drainage.

Adult↗

PubMed1987

Long-term follow-up study of patients after endoscopic sphincterotomy for choledocholithiasis.

Late complications have been examined in 96 patients consecutively treated for choledocholithiasis by endoscopic sphincterotomy in the years 1976 to 1980. Forty-four of the patients (46%) had the gallbladder in situ. Patients treated for short-term complications--that is, in the 1st month after sphincterotomy--are not included in this study. The mean length of follow-up study was 4.1 years (range, 2 months to 8 years and 9 months). Late bile duct symptoms occurred in seven patients (7%): three (6.8%) in patients with the gallbladder in situ and four (7.6%) in cholecystectomized patients. Stones were found in the common bile duct in three of these patients, one with and two without the gallbladder. The median duration from sphincterotomy to late complication was 8 months (range, 2 months to 5 years). Six of the patients had cholangitis, and the seventh had jaundice with abdominal pain. Two of the patients died of their complications. In conclusion, our results indicate that the frequency of late complications to endoscopic sphincterotomy is low and apparently independent of possible prior cholecystectomy.

Aged↗

PubMed1999

[An extremely elderly patient with choledocholithiasis and many complications].

It was very difficult to treat a 90-year-old woman for choledocholithiasis with acute obstructive suppurative cholangitis, gallbladder perforation, and a pool of bile in the right perirenal spase. Extracorporeal shockwave lithotripsy (ESWL) was performed after emergency percutaneous transhepatic biliary drainage (PTBD), but we could not perform lithotripsy successfully because of large and hard stones. Although Endoscopic sphincterotomy (EST) was performed using an ultratome by rendezvous method. Lithotripsy was finally successful, after three times endoscopic mechanical lithotripsy (EML) and procedure using an endotriptor for basket impaction. It is very important in advanced aged patients that endoscopic treatment should be performed step by step.

Aged↗

PubMed1983

Ultrasonography of choledocholithiasis.

In a retrospective study of patients with ultrasonographically demonstrable choledocholithiasis, 81 stones were demonstrated in 46 patients. The majority of the stones were between 5 and 10 mm in diameter; the smallest was 2 mm and the largest 23 mm. Of the 81 stones, 64 demonstrated acoustical shadowing; 56 were located in the distal segment of the common bile duct. Stones in the common bile duct are best demonstrated by sagittal sections with the patient in the right anterior oblique position. It is possible but more difficult to demonstrate stones within a normal-sized common bile duct. Several possible sources of confusion in the diagnosis of common bile duct stones are discussed. Ultrasonography of the common bile duct is best performed with a high-resolution real-time sector scanner. The accuracy and frequency of detection of common bile duct stones have increased significantly with the advances in technology and improvement in resolution of the mechanical sector real-time scanners.

Diagnostic Errors↗

PubMed2001

Laparoscopic ultrasonographic appearance of the common bile duct mucosa: a predictor of choledocholithiasis.

Previously we reported on the use of laparoscopic ultrasonography in detecting common bile duct stones during laparoscopic cholecystectomy. The aim of this study is to describe the laparoscopic ultrasonographic appearance of the common bile duct mucosa in patients with choledocholithiasis. Medical records of 44 patients with an increased risk for common bile duct stones undergoing laparoscopic cholecystectomy between 1993 and 1998 were reviewed. In the operating room, the laparoscopic ultrasonographic appearance of the common bile duct mucosa was scored in real time as normal, mild changes (hyperechoic mucosa), or severe changes (hyperechoic with mucosal thickening). Of the 31 patients (70%) with stones or sludge in the biliary tree, 29 (94%) had either severe (58%) or mild (36%) hyperechoic and 2 (6%) had normal-appearing common bile duct mucosa on laparoscopic ultrasonography. Of the 13 patients (30%) with no documented stones or sludge, 11 (85%) had normal and 2 (15%) had mild hyperechoic common bile duct mucosa on laparoscopic ultrasonography. Both of these patients had laboratory values indicating recent passage of common bile duct stones. The association between common bile duct stones and the presence of hyperechoic common bile duct mucosa was statistically significant (P < .0001, Fisher's exact test). This is the first report of hyperechoic common bile duct mucosa demonstrated by laparoscopic ultrasonography as a predictor of common bile duct stones. This finding is evident in the majority of patients with common bile duct stones and also may be associated with recent passage of a stone into the duodenum.

Cholangiography↗

PubMed1999

[Minimally invasive methods for treatment of cholelithiasis, complicated by choledocholithiasis].

Disease of the common bile duct (choledochal duct) was revealed in 18 from 531 patients with bile tract lithiasis (3.4%), who underwent laparoscopic cholecystectomy and in 3 of 72 patients (5.4%), who underwent cholecystectomy through minilaparotomy approach. Stenosis of the large duodenal papilla was observed in 14 patients, choledocholithiasis in 9 patients. Endoscopic papillosphincterotomy (EPST) was performed in all cases. There were no complications. In 2 cases moderate amylasemia was detected. Laparoscopic cholecystectomy was performed 5 days after the procedure on the large duodenal papilla (5.1 days mean). Intervention with the use of mini-approach after EPST was carried out in patient with concrement of gall bladder duct stump, which was revealed 3 months after laparoscopic cholecystectomy. Mini-approach made it possible to perform reconstructive operations on bile ducts in combination with cholecystectomy in 3 patients. At present there are many tools which enable combined treatment of the bile tract lithiasis complicated by bile ducts pathology with low-invasive technique.

Adult↗

PubMedDate not supplied

Recognition of ERC-induced pancreatitis in patients with choledocholithiasis by an analysis of laboratory findings.

BACKGROUND/AIMS: This study retrospectively analyses the relative value of various laboratory tests in the diagnosis of procedure-related pancreatitis in patients submitted to endoscopic retrograde cholangiography with sphincterotomy due to choledocholithiasis. METHODOLOGY: A detailed laboratory assessment was performed on 238 patients 4, 10, 24, 48 and 72 hours after undergoing endoscopic sphincterotomy. RESULTS: Of the 238 patients analyzed, 16 (6.7%) had a complication, including pancreatitis in 6 (2.5%), hemorrhage in 4 (1.7%), acute cholangitis in 3 (1.3%), and perforation in 3 (1.3%). In patients developing acute pancreatitis a significant rise was noted not only in serum amylase but also in the white blood cell count and aspargine transaminase at 24 hours following endoscopic sphincterotomy. Endoscopic procedure (difficulty in cannulating the bile duct and/or obtaining cholangiogram) was a significant risk factor for complications. CONCLUSIONS: It is possible to stratify patients according to their risk of developing pancreatitis according to serum amylase, white blood cells and aspargine transaminase levels monitored for at least 24 hours following ERC. Patients for whom the procedure was difficult and selective cholangiogram was not obtained are at increased risk of developing procedure-related complications.

Acute Disease↗