Postcholecystectomy choledocholithiasis

Postcholecystectomy choledocholithiasis

Any obstruction to the flow of bile can give rise to stasis, with the formation of stones within the duct. Duct stones may be detected many years after cholecystectomy and may also be related to the development of new pathology , such as infec tion of the biliary tree or infestation by Ascaris lumbricoides Clonorchis sinensis. The consequence of duct stones is either obstruction to bile flow or infection. Stones in the bile ducts are more often (80%) associated with infected bile than with stones in the gallbladder. Symptoms The individual may be asymptomatic; symptomatic patients with cholangitis have bouts of pain, jaundice and fever (‘Char cot’s triad’). Signs Febrile, icteric tenderness may be elicited in the epigastrium and right hypochondrium. Management It is essential to confirm that the jaundice is due to duct obstruction. Liver function tests and USG are the initial tests, and MRCP will identify the nature of the obstruction. Pus may be present within the biliary tree and liver abscesses may develop. Measures required include rehydration, atten tion to clotting, e xclusion of diabetes and the administration of appropriate broad-spectrum antibiotics. Once resuscitation has taken place, relief of the obstruction is essential. Endo scopic papillotomy/sphincterotomy is the pr eferred technique, followed by removal of the stones using a Dormia basket or placement of a stent or a nasobiliary drain for flushing if stone removal is not possible ( Figures 71.34 and 71.35 ). If this fails, PTC drainage can be done, with subsequent percutaneous choledochoscopy . Surgery , in the form of choledochotomy , is Jean Martin Charcot , 1825–1893, physician, La Salpêtrière, Paris, France. Enrico Dormia , 1928–2009, Professor of Urology , University of Milan and Chief of the Department of Urology , S Car aged by minimally invasive techniques.