Surgical Procedures/Abdominal Surgery/Choledocholithiasis

 Choledocholithiasis:  (Stones in the common bile duct)

Introduction:

 * In 10% of cases stones are found in the common bile duct.
 * Stones may form within the bile ducts.
 * Known as primary Bile ducts stones.
 * In majority of cases stones migrate from gall bladder.
 * Known as secondary bile duct stones.

Clinical Features:

 * Symptomatic.
 * Rerely asymptomatic.
 * e.g. Vague indigestion.
 * Pain:
 * Biliary Colic.
 * Jaundice:
 * Fever:
 * Chills and fever are usually associated with pain abdomen.


 * Other symptoms:
 * clay color stool.
 * Dark urine.
 * Symptoms associated with Pancreatitis.

Charcot's Triad:
Clasically seen in common-bile-duct-stone.

Fluctuating Jaundice + Pain RUQ + Fever ( with rigors )

Examination:
O/E: P/A:
 * Icterus (+).
 * Febrile.
 * RUQ tenderness.
 * NB ! Gall bladder not palpable.
 * "Courvoisier's Law".

Investigations:

 * Blood:
 * WBC: Normol. (Elevated when Cholangitis.)
 * Alkaline Phosthotase: Very high in Obstructive jaundice.
 * Serum billirubin: High.
 * Serum Alylase: High when associated pancreatitis.

Radiological investigations:

 * USG-Abdomen:
 * Ultra sound Should be done:
 * To know CBD size. (Normol ~8mm)
 * To detect common duct stones.


 * PTC:
 * ERCP is prefered.


 * ERCP:
 * Indication:
 * Sufferer with jaundice.
 * Advantages:
 * Shincterotomy.
 * Papillotomy.
 * stone removal.

Complication:

 * Suppurative Cholangitis:
 * Dangerous condition which will give liver failure and death if not timely *surgical intervention and antibiotic therapy.
 * Impairment of Liver function:
 * White Bile/Surgical Bile:
 * Seen when liver function is seriously depressed.
 * Hydro-Hepatis:
 * Rare condition.
 * Stone may ulcerate:
 * Through the common bile duct to cause biliary peritonitis.
 * Natural cure:
 * Rarely stone may ulcerate through the bile duct into the duodenumto cause natural cure.
 * Acute Panrcreatitis.

PreOperation Treatment:

 * AntiBiotic:
 * Broad Spectrum.
 * Analgesics.
 * AntiCholinergic:
 * Relaxant of Shincter of Oddi.
 * Vitamin K.
 * Glucose Drink.
 * High Carbohydrate with Low fat Diet.
 * Blood Transfusion:
 * To be used during Operation.
 * Mannitol.

Surgery:

 * Operated when Jaundice is not present.

Operation of Choice: 


 * Cholecystectomy.
 * Choledochotomy:
 * Supra-duodenal Choledochotomy.
 * Retro-duodenal Cholodochotomy.
 * Trans-duodenal Choledochotomy.

PostOperative Treatment:

 * T-tube/drainage:
 * Regular Bile examination:
 * Color and quantity.
 * If bile was White Bile, it's color should be normol within 2 days.
 * The quantity of drainage Bile should decrease.
 * Tube-Out after 7 to 10 days if:
 * T-Tube Cholangiography/PostOP. Cholangiography:
 * Should be performed before the T-tube removal.
 * When Tube is clamped and if no pain around gallbladder.
 * There is no obstruction in the bile duct.
 * Small silk suture at the edge of the wound and T-Tube pulled out.


 * Color Of faeces:
 * Pale or White:
 * When there is obstruction.
 * Normol yellow hue:
 * When there is no obstruction.