DISORDERS OF THE BILE DUCTS
(CHOLEDOCHUS)
CHOLEDOCHOLITHIASIS
CHOLANGITIS
TREATMENT OF COMMON DUCT STONES
STRICTURES AND BENING OBSTRUCTIVE
DISORDERS OF THE BILE DUCTS
TUMORS OF THE BILIARY TRACT
UNCOMMON CAUSES OF BILE DUCT
OBSTRUCTION
Congenital Choledochal Cysts, Caroli’s Disease,
Hemobilia, Pancreatitis, Ampullary Stenosis, Recurrent
Pyogenic Cholangitis (Oriental Cholangiohepatitis),
Sclerosing Cholangitis
CHOLEDOCHOLITHIASIS 1
Biliary pain
Jaundice
Episodic cholangitis
Gallstones in gallbladder or previous
cholecystectomy
General Considerations
15 % of patients with stone in the gallbladder
are found to harbor calculi within the bile ducts
5 % gallbladder is empty. (Otoctone stones)
50 % patients with CBD stones remain asymptomatic
Dilatation of CBD less marked
CHOLEDOCHOLITHIASIS 2
Clinical Findings
A) Symptoms
Asymtomatic
Biliary colic
Cholangitis
Pruritus
B) Signs
Icter, tenderness, fever, chills, toxic
CHOLANGITIS (Bacterial Cholangitis)
Acute cholangitis is an entity characterized by fever,
chills, upper abdominal pain and jaundice
Some degree of biliary ductal obstruction and
increased intraductal pressures
The important principle is that any case of
cholangitis can progress to shock and can be fatal if
neglected
Charcot triad= Acute cholangitis
Abdominal pain, jaundice, fever
Reynolds’ pentad= Toxic cholangitis
+ Confusion and hypotension
CAUSES OF ACUTE CHOLANGITIS 1
Gallstones
Bile duct stricture
Benign causes (bile duct injury, anastomotic stenosis)
Oriental cholangiopathy
Congenital anomalies (Choledochal cysts Caroli’s disease
Bile duct atresia)
Malignant causes
Cholangiocarcinoma
Pancreatic causes
Periampullary and duodenal carcinoma
Extrinsic compression of the bile duct
Parasitic infections
Clonorchis sinensis
Ascaris lumbricoides
CAUSES OF ACUTE CHOLANGITIS 2
Hemobilia
Iatrogenic
PTC or retrograde cholangiography (ERC)
Indwelling biliary catheter or endoprosthesis
Bile duct ischemia
ORGANIMS ISOLATED FROM THE
BILE IN CHOLANGITIS
Gram-negative bacteria
Klebsiella species 54 %
Esherichia coli 39 %
Enterobacter species 34
Psedomonas species 24
Citrobacter species 21
Gram-positive bacteria
Enterococcus 34
Streptococcal species 38
Anaerobes
Bacteriodes species 15
CHOLEDOCHOLITHIASIS 3
Labaratory Findings:
Leukocytosis ≥ 15.000/ μL
Bilirubin (2-4) 10 mg/dL
Alkaline phosphatase ↑, K glutamyltranferase
CA 19-9 ↑
US, spiral CT, MR Cholangiograpy
PTC
ERC end stenting