Choledocholithiasis - Causes, Clinical Features, Complication and Management

   

What is choledocholithiasis?

Definition: Choledocholithiasis refers to a condition when solitary or multiple stones are lodged within the lumen of any duct of the biliary system. 
The ducts mainly involved are the common bile duct, the cystic duct, and the common hepatic duct. 
The common bile duct ( CBD ) is mainly involved in Choledocholithiasis.
The common bile duct ( CBD ) is a tube carrying the bile formed in the gall bladder to the third part of the duodenum at the junction of the ampulla of Vater. At this junction, the main pancreatic duct is also open.

What are the types of bile duct stones?

A. Types of bile duct stone on the basis of their site of formation: 

Two types of stones are found in the common bile duct -

1. Primary bile duct stones 

These stones are primarily formed in the bile duct itself. This is a rare type.

2. Secondary bile duct stones  

These stones are primarily formed in the gall bladder lumen and migrate to the bile duct. The majority of bile duct stones are secondary stones.

B. Types of stones on the basis of their chemical nature:

1. Cholesterol stones - most common type, formed of cholesterol. These stones are yellow-green in color.
2. Pigment stones – rare, formed of bile pigment bilirubin as calcium bilirubinate salt. These types of stones are brown in color.
3. Mixed stones – These are a combination of cholesterol, bile pigments calcium, phosphates, protein, and cysteine. 

What are the risk factors of choledocholithiasis?

As the stones are not always primarily formed in the lumen of the common bile duct, rather it comes from the pre-formed stones of the gall bladder, the risk factors are the same as that of Cholelithiasis. 

The risk factors are following:

• 4F

                Female
                Fatty
                Forty
                Fertile

• Oral contraceptive pills ( OCP )
• Hormone replacement therapy
• Family history
• Rapid weight loss
• Diet - 

                High-calorie diet.
                Refined carbohydrates in the diet.
                Low fibers diet.

• Chronic liver disease – cirrhosis
• Infection –Cholangitis, Cholecystitis
• Hemolytic disease – sickle cell disease, hereditary spherocytosis

What is the Pathophysiology of choledocholithiasis?

Mainly there are four factors that contribute to the formation of stones.

These are:-

• Metabolic factors –
• Reflux factors -
• Stasis factors -
• Infective factors - 

Metabolic factors:-

The solubility of cholesterol depends on the concentration of conjugated bile salts ( bile acid ) and phospholipids. The normal ratio of bile acid to cholesterol is 25:1. But when this ratio alters and falls to 13:1 the cholesterol precipitates and thus stone forms.

Reflux factors:-

Reflux of pancreatic enzymes into the gall bladder is also considered the cause of cholesterol precipitation.

Stasis factors:-

Temporary cessation of bile flow into the intestine and stagnation of bile in the gall bladder is also the cause of stone formation. Stasis may predispose bacterial invasion and stone formation.

Infective factors:-

This factor is considered the main cause of stone formation. Mixed stones are said to be infective in origin. The causative organisms are – E. coli, Bacterium typhosum, Streptococcus, etc. 

What are the Causes of Choledocholithiasis?

Causes of cholesterol stones:-

When the ratio of bile acid and cholesterol in the bile juice decreases, the precipitation of cholesterol occurs which in turn leads to the formation of cholesterol stones.

The reason being:

Excessive cholesterol.

Excessive bilirubin.

Less bile salts.

Parenteral nutrition.

Prolong fasting

Infections 

Causes of pigment stones:-

When excessive bile pigments are excreted in the bile juice the precipitation of bile occurs and pigment stones are formed.

The reason being:

Haemolytic diseases – sickle cell disease, haemolytic anemia, septic haemolysis, malaria.

Cirrhosis

Infections 

What are the signs and symptoms of choledocholithiasis?

Pain – Present is predominantly felt in right hypochondrium, and may be present in the epigastric region, and is radiating to the right shoulder and back. Pain is exacerbated after fatty foods.

On examination, tenderness is elicited in right hypochondrium.

Fever with chill -

Jaundice - Icterus ie yellowish discoloration of the sclera is present.

Itching of the body – due to obstructive jaundice.

Loss of appetite -

Dyspepsia -

Nausea and vomiting -

Clay-colored stool -

Dark yellowish colored urine -

Charcot’s triad:

Abdominal pain – in the right hypochondrium.

Fever with chill

Fluctuating Jaundice – due to obstruction of the common bile duct. 

What are the Complications of choledocholithiasis?

Hepatitis – inflammation, and impairment of liver function

Pancreatitis – inflammation pancreas

Cholangitis – Inflammation of the biliary tract

Cholecystitis – Inflammation of gall bladder.

Hydro-hepatosis – gross dilatation of the intrahepatic biliary canaliculi is also seen. Although this is a rare condition.

Peritonitis – when stone ulcerate to peritoneal cavity and infection of the perineum is leading to peritonitis.

What is the Diagnosis of choledocholithiasis?

Haematology -

Haemoglobin

Total leukocyte count

Differential leukocyte count

Urine examination –

Bile pigment may be seen. 

Biochemistry –

Liver function test ( LFT ) - 

                              Serum bilirubin - Direct

                                                        - Indirect

                               Alkaline phosphatase 

                               SGPT - Serum Glutamic Pyruvic Transaminase ( ALT )

                               SGOT - Serum Gluamic Oxaloacetic Transaminase ( AST )

                               GGT - Gamma-glutamyltransferase

Kidney function test ( KFT ) -

                        Blood urea

                        Serum creatinine

Imaging/Radiology:

Transabdominal ultrasound

Abdominal CT scan

Endoscopic ultrasound

Endoscopic retrograde cholangiography ( ERCP )

Magnetic resonance cholangiography ( MRCP )

Magnetic resonance imaging ( MRI )

Percutaneous transhepatic cholangiogram ( PTCA)

Hydroxyl iminodiacetic acid scan ( HIDA SCAN ) 

What is the management/treatment of choledocholithiasis? 

Conservative management:

An antibiotic – broad-spectrum antibiotic is given to prevent cholangitis.

Analgesic –

Antispasmodic drugs –

Anticholinergic – given to relax the sphincter of Oddi.

Glucose iv or orally given 

Surgical management:

Stone extraction by surgery

Lithotripsy

Cholecystectomy

Biliary endoscopic Sphincterotomy

Biliary stenting.

What are the preventions of choledocholithiasis?

Physical activity – avoid a sedentary lifestyle. Make routine exercises regularly.

Take a High fiber diet

Take Low cholesterol diet

Avoid prolonged fasting.

 

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