Choledocholithiasis is the presence of stones in bile ducts; the stones can form in the gallbladder itself or in the bile ducts. These stones can cause biliary colic, biliary closure, gallstone or cholangitis (bile duct infection and inflammation). Cholangitis, can lead to stenosis, stasis and choledocholithiasis. The definite diagnosis requires a representation by the ultrasound – sometimes EUS, MRCP or ERCP. Early endoscopic or surgical relief is displayed.
(See also Overview biliary function.)
Choledocholithiasis is the presence of stones in bile ducts; the stones can form in the gallbladder itself or in the bile ducts. These stones can cause biliary colic, biliary closure, gallstone or cholangitis (bile duct infection and inflammation). Cholangitis, can lead to stenosis, stasis and choledocholithiasis. The definite diagnosis requires a representation by the ultrasound – sometimes EUS, MRCP or ERCP. Early endoscopic or surgical relief is displayed. (See also Overview biliary function.) Stones can be described as primary stones (generally brown pigment stones), which form in the bile ducts secondary stones (generally cholesterol stones) that form in the gallbladder and before they migrate Residualsteine ??in the bile ducts, the (evident <3 years later) Recurrent stones in the corridors typically> develop three years after surgery were left behind in the cholecystectomy under way in developed countries> 85% of the stones in the common bile duct are secondary. Affected patients usually have additional stones in the gallbladder. Up to 10% of patients with symptomatic gallstones addition stones have in common bile duct. Brown pigment stones, which occur after a cholecystectomy, arise due to a stasis of bile (z. B. postoperative stricture) and subsequent infection. The relative proportion of bile duct stones, which are pigmented, increases after a cholecystectomy with time. Bile duct stones can come off into the duodenum without symptoms. Biliary colic occur when the gears are partially closed. A complete lining of the bile duct causes a transition enlargement, jaundice, and in the further course cholangitis (a bacterial infection). Stones that move the ampulla of Vater can cause biliary pancreatitis. In some patients (mostly elderly), a biliary obstruction manifested by stones that were asymptomatic in the past. In acute cholangitis in biliary obstruction occur bacteria from the duodenum into the bile ducts. The majority (85%) of cases is due to stones in the common bile duct, however, a biliary obstruction can also be caused by tumors or other causes due to his (causes of biliary obstruction). Typical bacterial pathogens are gram-negative rods (such as. For example, Escherichia coli, Klebsiella sp., Enterobacter sp), less common gram-positive bacteria (e.g., B. Enterococcus spp.) And anaerobes (z. B. Bacteroides sp., Clostridia sp .). The symptoms consist of abdominal pain, jaundice and fever or chills (Charcot’s triad). The abdomen is sensitive to pain and often the liver is sensitive to pain and enlarged (Leberabszessbildung). Confusion and hypotension associated with a mortality rate of approximately 50% and high morbidity. Causes of biliary obstruction stones (often) violation of Gallgengans due to surgery (often) tumors scarring due to chronic pancreatitis External compression by a cyst, a herniation or aneurysm of the common bile duct (choledochozele) or a pancreatic pseudocyst (rare) Extrahepatic or intrahepatic strictures due to primary sclerosing cholangitis or AIDS-related cholangiopathy cholangitis parasites with Clonorchis sinensis or Opisthorchis viverrini parasites migration of Ascaris lumbricoides in the common bile duct (rarely) Recurrent purulent e cholangitis (Oriental cholangiohepatitis, hepatolithiasis) is characterized by intrahepatic formation of brown pigment stones. This disease occurs in Southeast Asia. Here, sludge and bacterial debris deposited in the bile ducts. Malnutrition and parasites (eg. B. Clonorchis sinensis, Opisthorchis viverrini) increase the risk. Parasites can cause obstructive jaundice with intrahepatic duct inflammation, proximal stasis, stone formation and cholangitis. Repeated cycles of obstruction, infection and inflammation lead to bile duct and biliary cirrhosis. The extrahepatic transitions are dilated rule in, but the intrahepatic ducts appear normal due to the periductal fibrosis. In AIDS associated cholangiopathy or cholangitis cholangiography anomalies (h i. E. Multiple stenoses and extensions that intra- and extrahepatic bile ducts concern) can be similar to those of primary sclerosing Cholangitisoder Papillary show. Etiology is probably an infection based, probably with cytomegalovirus, Cryptosporidium sp. or microsporidia. Diagnostic liver function tests sonography Suspicion of stones in the common bile duct is given to patients with jaundice and biliary colic. Fever and leukocytosis suggest a acute cholangitis. Elevated levels of bilirubin and especially alkaline phosphatase, ALT and GGT are part of the extrahepatic closure and suggest stones, v. a. in patients with features of acute cholecystitis or cholangitis. The ultrasound Can stones in the gallbladder and sometimes in the common bile duct show (less accurate). The common bile duct is dilated (> 6 mm in diameter with intact gall bladder,> 10 mm after cholecystectomy). If at an early stage any advanced courses are available (eg. As on the first day), the stones are likely to come off spontaneously. If in doubt, MRCP yields very reliable results when impacted stones. ERCP is performed at non-unique MRCP findings, it can be used both therapeutically and diagnostically. Computed tomography can detect liver abscesses, even if it is less accurate than ultrasound. Suspicion of acute cholangitis, a complete blood count and blood cultures are essential. Leukocytosis is common and transaminases may rise up to 1000 I.E./l; let a cell necrosis such. B. as a result of micro-abscesses suspect. The results of resistance testing in the blood cultures helps to focus the antibiotic therapy. Therapy ERCP and sphincterotomy case of suspected a stone-induced closure of the bile duct and an ERCP a papillotomy for the removal of the stone must be performed. The success rate is over 90%; up to 7% of patients have early complications (eg. B. bleeding, pancreatitis, infection). Late complications (eg. As stone recurrence, fibrosis and subsequent transition narrowings) are more common. A laparoscopic cholecystectomy, which is not the appropriate process for operative cholangiography or an exploration of the bile duct can be electively performed after ERCP and papillotomy. Mortality and morbidity after an open cholecystectomy with common bile duct investigation are higher. In patients with high risk of complications at a cholecystectomy, for. As elderly patients, the sole Papillotomy an alternative. Acute cholangitis is an emergency situation that requires aggressive treatment and an urgent endoscopic or surgical removal of the stones. Antibiotics, similar to those for acute cholecystitis, be given (Acute cholecystitis: therapy). An alternative therapy for very sick patients is imipenem and ciprofloxacin and metronidazole for anaerobes cover. In recurrent suppurative cholangitis the goal is accompanied by supportive measures (eg. As broad spectrum antibiotics) to eliminate all parasites and endoscopically (via ERCP) or surgery to free the courses of stones and debris. Important Points In developed countries form> 85% of the stones in the gallbladder and migrate to the bile ducts; usually there are cholesterol stones. The frequent common bile duct stones should be suspected in patients with biliary colic, unexplained jaundice and / or elevated alkaline phosphatase and gamma glutamyl transferase levels. It should be made ultrasonography and MRCP findings are inconclusive. With ERCP and sphincterotomy a stone is removed, causing a closure. In acute cholangitis, the stones are removed as soon as possible and given antibiotics.