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home - Biliary - Gallstone Disease - CBD Stones Written by Dr Sebastian Zeki
Knowledge


Knows the physiology and biochemistry of bile and the pathogenesis
of gallstones

Is familiar with the normal anatomy and the anatomical variations of
the biliary tree

Recognises the symptoms and signs of the potential complications of
galllstone disease including biliary colic acute cholecystitis jaundice
due to calculous bile duct obstruction cholangitis and carcinoma

Knows the various techniques of diagnostic imaging including
ultrasound CT MRI ERCP EUS radionuclide techniques

Knows the various treatment options the indications for operative and
non-operative management and the risks of each

Knows the current national guidelines for use of ERCP and the risks
of the technique

Knows the ways in which gallbladder polyps are diagnosed and
managed

Knows that gallbladder and sphincter of Oddi dysfunction (SOD) may
account for otherwise unexplained abdominal pain

Recognises different types of SOD how they may present and how
they are investigated

Skills
Can select the most appropriate diagnostic and therapeutic
techniques for each clinical situation

Recognises possibility of diagnostic uncertainty in biliary dysmotility
and shows thoughtful judgement in each individual situation

Behaviours
Makes appropriate assessment stratifies urgency and plans
management of patients who have complications of gallstones

CBD Stones

? Management Pathogenesis Diagnosis tests:-USS- not sensitive for small stones (20% cases).-ERCP for therapy and diagnosis.-MRCP (95% concordance with ERCP if stone>1cm) if not jaundiced.-EUS may be useful in patients in whom ERCP was unsuccessful or undesirable. Laboratory tests: -Increased wcc.-Cholestatic lfts.-Raised amylase 3-4x normal- if in 1000’s usually microabscesses are present. Complications CBD (usually calcium bicarbonate stones) Bile Duct Obstruction Bacterial Cholangitis Bile duct strictures Malignant strictures Stent while awaiting surgical decision - 20% block in 3 mnths with Ca Benign stricture ERCP Surgical roux loops Biliary fistula Haematobilia Oriental cholangiohepatitisbefore the age of 50 Common Bile Duct Stones ERCP-Stent as definitive if the patients is too unwell.-Mechanical lithotripsy/ ESWL with further ERCP to retrieve fragments can be used.-Cholecystectomy with CBD exploration (if emergency, choledo-chotomy with placement of a large-bore T tube carries a lower mortality compared to cholecystectomy with CBD exploration.-Percutaneous cholecystostomy tube if ERCP unavailable/ unsuccess-ful. Disrupted mechanical barrier with only partial drainage can cause cholangitis as bacteria enter without impedance Bacteria also enter SOD without disruption and use obstruction as nidus- 70% of obstructed bile has bacteria within (mixed growth) Barriers against infectiona)Sphincter of Oddi -mechanical barrier b) The continuous flushing action of bile c) Bacteriostatic bile salts d) Secretory IgA and biliary mucous are antiadherent factors Indications for urgent biliary decompression include: (in summary persistence of any feature of Reynold’s pentad)Persistent abdominal pain Hypotension despite adequate resuscitation Fever greater than 39ºC (102ºF) Mental confusion, which is a predictor of poor outcome Antibiotics Mechanism of bacterial entry into the biliary tract Bacterial features enhancing pathogenicity include:f)External pili in Gram -ve Enterobacte-riaceae, which facilitate attachment to foreign surfaces such as a stone or stent.g)A glycocalyx matrix composed of exopolysaccharides produced by bacteria which protect the organisms from host defense mechanisms and may hinder penetration of antibiotics. CompromisedHepatic tight junctions Kupffer cells Bile flow IgA production Obstruction Normal Obstruction raises the intrabiliary pressure and promote entry of bacteria from portal circulation Gallstone Ileus In 20% dont respond therefore urgent biliary decompression needed. 80 % respond OrganismsThese are the same as acute cholecystitis. Clinical Presentation Most are symptomatic Charcot triad is fever, RUQ pain and jaundice — occurs in only 65 % Reynold's pentad is Charcot’s + Confusion and hypotension- assoc 50% mortality. Hypotension - may be the only presenting symptom in elderly or those on corticosteroids Risk Factors For CBD Stones Specifically15% are de novo stones in the CBD.50% have stones in the CBD as well as the gallbladder (increased with increasing age and Asians).90% with CBD stones have a gallbladder stone. The diet is low in fat. Bile duct sludge is a risk factor. Ampullary stenosis can be a risk- most are symptomatic.

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