Anatomy of Biliary tree

Common bile duct (CBD) stone (Choledocholithiasis) Choledocholithiasis is a disease of the common bile duct. The common bile duct forms at the junction of the cystic duct (from the gallbladder) and the common hepatic duct (from the liver). It drains bile into the duedenum (the first part of the small intestine).

Location of Gall stone 1. 2. 3. 4. Gallbladder (Cholecystolithiasis) Cystic duct (Cysticolithiasis) Common bile duct (Choledocholithiasis) Common hepatic duct (Hepatolitiasis)

Type of CBD stone 1. Cholesterol stones 2. Pigment stones a. Black-pigment stones b. Brown-pigment stones Risk Factor cholesterol stones include: o High serum cholesterol leves

o o o o o o

Increased age Female sex Obesity Rapid weight loss The contraceptive pill Total parenteral nutrition

pigment stones include: o o o Chronic haemolysis (red blood cell breakdown) -hereditary spherocytosis Sickle cell disease, as well as liver cirrhosis. They may also form in the bile ducts after cholecystectomy (surgical

removal of the gallbladder).

Clinical manifestation Symptoms usually do not occur unless the stone blocks the common bile duct. Symptoms that may occur include: o Abdominal pain in the right upper or middle upper abdomen that may: o Be steady o Be sharp, cramping, or dull o Spread to the back or below the right shoulder blade o Fever o Loss of appetite o Jaundice (yellowing of skin and whites of eyes) o Nausea and vomiting

How is Common Bile Duct Stone diagnosed Clinical symptom & Clinical examination Laboratory test :

Full blood count - elevated white cell count signifying infection. Liver function tests - elevated bilirubin, evidence of stasis.

Blood cultures - frequently positive in cholangitis. Amylase/Lipase - may be elevated if there is an element of pancreatitis.

Imaging Abdominal CT scan Abdominal ultrasound Endoscopic retrograde cholangiography (ERCP) Endoscopic ultrasound Magnetic resonance cholangiopancreatography (MRCP) Percutaneous transhepatic cholangiogram (PTCA)

Complication

Biliary cirrhosis Cholangitis Pancreatitis

Treatment o Surgery : ERCP and a procedure called a sphincterotomy o Laparascopic Cholecystectomy + pre op ERCP o Laparascopic cholecystectomy + intra op ERCP o Laparascopic Cholecystectomy + CBD exploration(transcystic / choledochotomy) o open cholecystectomy + CBD exploration

Surgery risk
The major risk of an ERCP is the development of pancreatitis Heart and lung problems Bleeding after sphincterotomy Infection in the bile duct (cholangitis) perforation (a tear in the intestine) Over sedation can result in dangerously low blood pressure, respiratory depression, nausea, and vomiting.

Pathogenesis
PREDISPOSING/ NON-MODIFIALBE GENDER: FEMALE AGE: 40 MULTIPAROUS PRECIPITATING/ MODIFIABLE LIFESTYLE FERTILE DISEASE

AGEING ESTROGEN IN WOMEN USE OF ORAL CONTRACEPTIV ES

MEDICATION SUCH AS CLOFIBRATE

ILEAL DISEASE INTESTINAL BYPASS SURGERY

PREGNANCY STARVATION RAPID WEIGHT LOSS

FATTY LIVER

SERUM CHOLESTEROL LEVELS

BILE ACID SYNTHESIS

MALABSORPTION OF BILE SALTS

BILE COMBINES WITH CHOLESTEROL IN THE LIVER

EXCRETION OF GALL BLADDER SLUDGE

HEPATIC SECRETION OF SUPER SATURATED

EMULSIFICATION OF CHOLESTEROL

SLUGGISH BILE FLOW

CHEMICAL IRRITATION TO BALLDER

PRECIPITATION OF CHOLESTEROL/PI GMENT CRYSTALS CHOLESTEROL/PIGM ENT STONE FORMATION IN THE GALL BLADDER

CHOLECYS TITIS

INFLAMMATION OF THE GALLBLADDER

CHOLELITHIASIS

STONE FORMATION IN THE HEPATIC DUCT DISLODGEME NT OF STONE IN THE COMMON

NAUSEA/VOMITING FEVER CHILLS PAIN ALTERATION IN THE ABSORPTIVE CHARACTERISTIC OF THE MUCOSAL LAYER EXCESSIVE BELCHING ABDOMINAL DISTENTION PAIN ABSORPTION OF WATER AND BILE SALTS CHOLEDOCOLITHIASIS OBSTRUCTION OF GALL STONES AND INFLAMMATIO N OF THE COMMON BILE DUCT

SIGNS/SYMPTOMS MANIFESTED ON THE PATIENT: BILIARY COLIC

SUPER SATURATION OF CHOLESTEROL IN THE BILE ON THE GALL BLADDER

JAUNDICE YELLOWISH CONJUNCTIVA TENDERNESS IN THE RIGHT UPPER QUADRANT OF THE ABDOMEN