Gall stone disease or Cholelithiasis is characterized by stone formation in the Gall Bladder. The Gall stones can be cholesterol stones or pigment stones or mixed stones. The various causes of gall stone formation are obesity, high fat diet, genetic (hereditary), some medications etc. Presence of stones in the gallbladder is referred to as cholelithiasis,  Gall stones or Cholelithiasis is a metabolic disease characterized by formation of stones either pigment / cholesterol / mixed stones in the gall bladder. from the Greek chol- (bile) + lith- (stone) + iasis- (process). If gallstones migrate into the ducts of the biliary tract, the condition is referred to as choledocholithiasis, from the Greek chol- (bile) + docho- (duct) + lith- (stone) + iasis- (process). Choledocholithiasis is frequently associated with obstruction of the biliary tree, which in turn can lead to acute ascending cholangitis, from the Greek: chol- (bile) + ang- (vessel) + itis- (inflammation), a serious infection of the bile ducts. Gallstones within the ampulla of Vater can obstruct the exocrine system of the pancreas, which in turn can result in pancreatitis.

 

Etiology and pathogenesis

presentation - sign and symptoms

Investigations

Differential diagnosis

Management

Prevention

 Complications

 

 

 

This is divided into 4 parts

anatomy of extra-hepatic bile ducts

Causes of CBD stones

Medical Management

Surgical management

 

Cholangitis

Acute cholangitis was first described by Charcot as hepatic fever in 18771. The diagnosis of acute cholangitis has been made based on Charcot's triad which was described as co-existence of

Charcot's Triad

1. Right upper quadrant pain

2. Jaundice

3. Fever

Tokyo Guidelines for management of Acute Cholangitis and cholecystitis was spublished in 2007 and revised criteria were published in year 2013.

Tyokyo Guidelines

(A) Systemic inflammation (A-1, fever and / or shaking shills), (A-2 laboratory data for inflammatory response)

(B) Cholestasis (B - 1, Jaundice, B - 2, abnormal liver function tests)

(C) Imaging (C - 1, Biliary dilatation, C -2, evidence of etiology on imaging, such as stricture, stone, stent, etc.)

existence of one item in A section with one item in B or C sections is referred to as suspected diagnosis, while existence of at least one item from each section is referred to as "Definitive diagnosis" 2.

 

 

References

  1. De la Charcot M (1877) Fievre hepatique symptomatique comparison avec la fievre uroseptique. Lecons sur les maladies du foie voies biliares et des reins. Bourneville et severstre, Paris.
  2. Kiriyama S, Takada T, Strasberg SM, et. al. (2013). TG13 guidelines for diagnosis and severity grading of acute cholangitis. J Hepatobiliary  Pancreastic sciences. 20, 24-24.

Choledocho-duodenostomy

 

It is the anastomosis of the common bile duct with the duodenum either side to side or end to side.

 

History of choledocho-duodenostomy

In 1888 became the first choledochoduodenostomy, incidentally with bad result, was done by Riedel1.

Sprengel carried out in 1891 the first was a successful choledochoduodenostomy due to the presence of a choledochal stone2.

Mayo (1905) was the first to describe the application of this operation in a benign stricture of the ductus choledochus 3, while Sasse (1913) the indication area for choledochoduodenostomy was expanded to add papilla stenosis and pancreatic tumor4.

 

Indications for Choledocho-duodenostomy

Benign disorders

  • Choledochal stones
  • Hepatic stones
  • Papillary stenosis / strictures
  • post- cholecystectomy syndrome
  • Pancreatitis(??)
  • Benign strictures -  extra hepatic bile ducts
  • Parasitic infection
  • Inflammation of the CBD
  • Congenital disorders of the bile ducts

Malignant diseases

  • Pancreatic carcinoma
  • Extra hepatic biliary duct carcinoma (choliangio carcinoma)

 

Choledochoduodenostomy techniques

 

Sasse (1913) - anastomosis in retroduodenal part of CBD (obsolete), advantage - the duodenum and CBD lie absolutely over each other, no tension or stretch on anastomosis, disadvantage - damage to the pancreatic tissue

 

 

Some surgeons prefer transverse duodenostomy as the blood vesses run transversely over duodenum therefore less risk of blood loss than longitudinal incision

 

Classical Choledochoduodenostomy

 

Incision

References

 

  1. RIEDEL, BMCL (1892). Experiences about which gallstone disease with and without Jaundice. 116-119. Berlin publishing house of August Hirschwald.

  2. SPRENGEL, 0. (1891). About a case of gall extirpation of the bladder with attachment between a communication and ductus choledochus duodenum. Arch. Clin. C'hir. 42: 550-550.

  3. MAYO, WJ (1923). An address on the surgery of the hepatic and common bile ducts, Lancet 1: 1299-3002

  4. Sasse, F. (1913). About choledocho duodenostomy. Arch. Clin.Chir. 100: 969-984

Shiva and Shakti (Oil on Canvas 42"X32")

 

Lady in Red Veil (Green Eyes) oil on Canvas 42"X32"

 

Blowing Rose (Oil on Canvas 21"X27")

 

Man Kneeling (Oil on Canvas)

Muscular Man Crouching (oil on paper 23" X 32")

 

 

 

 

 

 

 

 

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