Postgraduate Medicine

ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20

Common bile duct stones Charles F. Gholson MD & Frank R. Burton MD To cite this article: Charles F. Gholson MD & Frank R. Burton MD (1992) Common bile duct stones, Postgraduate Medicine, 91:4, 113-118, DOI: 10.1080/00325481.1992.11701247 To link to this article: http://dx.doi.org/10.1080/00325481.1992.11701247

Published online: 17 May 2016.

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Date: 11 June 2016, At: 07:27

-@CME credit article

Common bile duct stones Detection and removal with endoscopic techniques

Charles E Gholson, MD Frank R. Burton, MD

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Preview Removal of the gallbladder does not automatically mean that a patient's biliary stone disease is cured. Gallstones can pass into the common bile duct and remain there undetected until they cause symptoms. Less often, stones are formed within the duct. The authors describe when to suspect that common bile duct stones are present and the best course to follow for definitive diagnosis and safe extraction.

Gallstones that escape the confines of the gallbladder or develop within the biliary tract afi:er cholecystectomy are encountered often by primary care physicians. Common bile duct stones are found in up to 15% 1'2 of the more than 600,000 cholecystectomies performed annually in the United States.3 The problem is especially common among the elderly. In up to 25% of elderly patients requiring gallbladder resection, common bile duct stones are present.4

Pathogenesis and clinical presentation Common bile duct stones are of two basic types: retained and recurrent. Retained (or residual) stones are discovered within 1 year of cholecystectomy and often were missed at surgery. Recurrent (or primary) stones presumably form de novo in the common bile duct. Retained stones are composed pri-

See related article, page 255.

marily of cholesterol, whereas recurrent stones are composed predominantly of calcium bilirubinate.4 While retained cholesterol stones are found most often, clinical distinction between the two types of stones is often impossible. Common bile duct stones are often detected soon afi:er cholecystectomy but may be the first manifestation of biliary tract disease. Patients usually have cholangitis, pancreatitis, or biochemical cholestasis in addition to biliary colic or nonspecific abdominal pain.4 Other complications may include obstructive jaundice, secondary biliary cirrhosis, hepatic abscess, and biliary duct stricture.

Clinical evaluation Electrocardiography, chest radiography, abdominal ultrasonography, a complete blood cell count, and measurement of serum liver enzyme, amylase, and lipase levels are needed for all patients presenting with biliary colic or a known complication of common bile duct

stones. Fever, jaundice, and elevation of liver and pancreatic enzyme serum levels (transaminases, alkaline phosphatase, amylase, and lipase) in a patient with abdominal pain suggest the passage or presence of a common bile duct stone. However, cholangiography is required for definitive diagnosis. In patients who have aT tube in place to drain the common bile duct afi:er cholecystectomy, a T-tube cholangiogram usually reveals any retained calculi. When aT tube is not present, another imaging method must be used (table 1). Computed tomography and ultrasound imaging of the common bile duct are much more sensitive in revealing complications than in detecting the stones themselves. Biliary imaging with endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography has greater than 90% sensitivity and is usually necessary to demonstrate the presence of a common bile duct ston~·6 as well as to rule out other lesions of the biliary tract. At present, ERCP is preferable·s because it allows simultaneous endoscopic imaging and removal of most common bile duct stones. Treatment considerations

Nonsurgical removal of retained and recurrent common bile duct

continued

VOL 91/NO 4/MARCH 1992/POSTGRADUATE MEDICINE • COMMON BILE DUCT STONES

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Endoscopic retrograde cholangiopancreatography has greater than 90% sensitivity in detecting a common bile duct stone.

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Table 1. Sensitivity of imaging methods in demonstrating common bile duct stones Imaging method

Sensitivity

Endoscopic retrograde cholangiopancreatography

>90%

Table 3. Factors limiting endoscopic management of common bile duct stones Coagulopathy Deep periampullary diverticulum

Percutaneous transhepatic cholangiography With duct dilation Without duct dilation

>90%

Common bile duct stones. Detection and removal with endoscopic techniques.

Common bile duct stones are frequently discovered after cholecystectomy or are the first sign of biliary tract disease. Because detection usually requ...
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