cbd stone medical

Common bile duct stones are a common cause of morbidity and mortality in adults. An increasing number of surgical and medical therapies are available to manage them, with different success rates reported. The various medical treatment strategies were developed during the last decade, but these medical modalities should not be contemplated as a first-line alternative of treatment. A consensus from experts is that there is no primary indication to use solvents on common bile duct stones because they have a relatively high rate of adverse effects and their success is limited compared with lithotripsy. However, there is a subgroup of patients in whom invasive or surgical treatment is risky or may fail. In these patients stone dissolution by solvent may constitute a plausible therapeutic alternative or may help reduce the size of the stones sufficiently to facilitate subsequent endoscopic extraction. Solvents may also be indicated in settings where endoscopic techniques or lithotripsy are not available and the patient has a T-tube in the common bile duct. Even in this condition, however, it is probably quicker and more effective to refer the patient to a center with expertise and technologic support to practice stone removal.

Often there are no symptoms for bile duct stones until a stone causes a blockage in the bile duct. Then symptoms can include:

To diagnose bile duct stones, we begin by conducting comprehensive exam and collecting a thorough history. Bile duct stones can sometimes be seen on an ultrasound or CT scan, although are most reliably diagnosed by either:

Diagnosing Stones in the Billiary Duct

Bile duct stones are typically removed using endoscopic retrograde cholangiopancreatography (ERCP), a minimally invasive procedure that combines x-ray and upper endoscopy—an exam of the upper gastrointestinal tract, consisting of the esophagus, stomach and duodenum (the first part of the small intestine)—using an endoscope, which is a lighted, flexible tube, about the thickness of a finger. The doctor passes the tube through the mouth and into the duodenum, then injects a contrast dye into the bile ducts, which can then be seen on x-ray. Special tools can be guided through the endoscope to remove the stones. Large or difficult-to-remove bile duct stones require special ERCP treatments that are not widely available at hospitals throughout the country. They include: Mechanical lithotripsy: This procedure involves breaking up a larger bile duct stone by capturing it and then crushing it in a wire “basket” that is inserted through the endoscope. Once the stones are crushed, they are removed using special tools through the endoscope. Intraductal electrohydraulic lithotripsy: For this procedure, we use a very fine probe inserted through a tiny scope that is passed through the ERCP endoscope. The probe, which is connected to a generator, provides a shock wave that breaks up the stone. Once the stones are crushed, they are removed using special tools through the endoscope. Patients can typically go home same day, once their sedation wears off.

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Bile duct stones are gallstones in the bile duct. They can start in the gallbladder and migrate into the bile duct or they can form in the bile duct itself. The stones can become lodged in the bile duct, causing a blockage. At the Bile Duct and Pancreatic Diseases Program, part of the University of Michigan’s Division of Gastroenterology, our multidisciplinary team provides the newest in minimally invasive treatments for bile duct stones. These treatments are not widely available and are performed by experienced gastroenterologists with high volumes in these procedures. Gallstones and bile duct stones (also known as choledocholithiasis) are the same, just located in two different areas of the body. Stones may pass spontaneously out of the bile duct on their own. However, when a stone gets stuck in the bile duct, medical intervention is necessary, otherwise inflammation, bacterial infection, and even severe organ damage can occur.

Symptoms for Bile Duct Stones

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Extracorporeal shock wave lithotripsy (ESWL) was investigated initially for treatment of gallbladder stones, but a high stone recurrence rate has limited its use in this condition. 5 In recent years high energy ESWL has been used with more promising results in high risk patients with common bile duct stones.

In this case, given the patient’s age and comorbidities it was decided that this was the treatment of choice. Biliary drainage was achieved during initial ERCP using a pigtail stent.

Q2: What does the post-treatment ercp film (fig1 in questions; see p 178) show?

The main complication is cholangitis (1%–8%) and this is reduced by use of prophylactic antibiotics. 1, 6 Procedure related mortality has not been reported.

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At repeat ERCP the pigtail stent was removed and the cholangiogram shows no evidence of calculi with satisfactory drainage from the common bile duct.

Final diagnosis

Traditionally such patients have been referred for surgical exploration of the common bile duct but this procedure is not without risk, particularly in elderly patients or those with major medical comorbidities. 4