Bile Duct Stone Formation Research Articles

Bile duct stone formation around a nylon suture after gastrectomy: A case report

BackgroundMany cases of choledocholiths formed around sutures and clips used during cholecystectomy have been reported. We describe a case of gallstone formation around a nylon suture after non-biliary surgery. To the best of our knowledge, this is the first report of such a case.Case presentationA 75-year-old Japanese man, who had undergone distal gastrectomy for gastric cancer and reconstruction with the Billroth II method 8 years earlier, presented with gastric discomfort. Abdominal ultrasonography was conducted and we diagnosed cholecysto-choledocholithiasis with dilatation of the intrahepatic bile duct. He underwent cholecystectomy and cholangioduodenostomy for choledocholith removal. Gallstones, which had formed around a nylon suture used during the previous gastrectomy, were found in the bile duct. Sutures of the same material had also been placed on the duodenum. Chemical analysis revealed that the stones were composed of calcium bilirubinate. The patient was discharged on postoperative day 19, and choledocholithiasis has not recurred thus far.ConclusionThe findings from this case suggest that standard, non-resorbable sutures used in gastrectomy may be associated with the formation of bile duct stones; therefore, absorbable suture material may be required to avert gallstone formation even in the case of gastrectomy.

The Underlying Mechanisms: How Hypothyroidism Affects the Formation of Common Bile Duct Stones—A Review

For decades, one well-known risk factor for the development of gallbladder stones has been hypothyroidism. Recent studies have interestingly reported that the risk in particular for common bile duct (CBD) stones increases in clinical and subclinical hypothyroidism. There are multiple factors that may contribute to the formation and/or accumulation of CBD stones in hypothyroid patients, including decreased liver cholesterol metabolism, diminished bile secretion, and reduced sphincter of Oddi relaxation. This paper focuses on the mechanisms possibly underlying the association between hypothyroidism and CBD stones. The authors conclude that when treating patients with CBD stones or microlithiasis, clinicians should be aware of the possible hypothyroid background.

A Unique Case of Accelerated Common Bile Duct Stones/Biliary Sludge Secondary to Tacrolimus Use in a Kidney Transplant Recipient

Purpose: Organ transplant recipients are at high risk for complications of biliary calculi. Use of certain immunosuppressant's has been associated with increased incidence of cholelithiasis with exact etiology being unknown. We show a unique example of accelerated common bile duct (CBD) stone and biliary sludge formation over a short period of time in a patient taking tacrolimus. A 48-year-old Hispanic male with end stage renal disease status post two kidney transplants on tacrolimus, presented with complaint of intermittent colicky epigastric pain for two weeks getting progressively worse, aggravated by food and associated with nausea and vomiting. Physical exam revealed icterus of sclera and skin with epigastric tenderness. Lab studies revealed protein= 7.2, albumin=3.5, bilirubin=6.7 (conjugated=1.3), ALP=381, AST=108 &\and ALT=73. Imaging studies revealed marked intra and extrahepatic biliary dilation with suspected choledocolithiasis with no evidence of gallstones. Endoscopic retrograde colangiopancreatography (ERCP) revealed multiple filling defects of more than 1 cm, which was consistent with CBD stones. Adequate size sphincterotomy was performed and plastic stent was placed. Subsequently, he underwent cholecystectomy and CBD exploration with T-tube placement. T-tube cholangiogram was performed, with no evidence of biliary stricture or calculi seen. He presented again after 11 weeks with similar symptoms. Laboratory studies revealed protein=7.8, albumin=4.1, bilirubin=5.3 (conjugated=1.3), ALP=233, AST=102 and ALT=188. Imaging revealed marked intra and extrahepatic biliary dilation with absent gallbladder. ERCP was performed revealing multiple CBD stones & biliary sludge. Review of literature shows that some adverse effects from tacrolimus result in increased incidence of biliary sludge and gallstone formation. Regular ultrasound to detect biliary disease is recommended in such patients. Cholecystectomy is also indicated in patients showing evidence of cholecystitis. However, there are no reports of CBD stone and biliary sludge formation in such a short interval of time in post-sphincterotomy patient as seen in our case. We hypothesize that relapse of stone formation in our patient was due to usage of tacrolimus. Controlled studies are needed to investigate exact incidence and to document association between accelerated CBD stone formation/biliary sludge and tacrolimus use. Exact mechanism for formation of CBD stones and biliary sludge in such a short time interval in such patients remains unknown.

The Clip That Got Away: A Migrated Cholecystectomy Clip as a Nidus for Distal Common Bile Duct Obstruction and Stone Formation

Purpose: 43 year old male presented with a one week history of fatty food intolerance, clay colored stools, and right upper quadrant pain. He underwent cholecystectomy 2 years ago for cholelithiasis and similar pain. A right upper quadrant ultrasound showed no ductal dilation, no intraductal lesion, and confirmed a previous cholecystectomy. Within 6 hours of admission, his bilirubin and alkaline phosphatase were double the normal values and his transaminases were seven times the normal values. A CT scan of the abdomen and pelvis with IV contrast showed no abnormalities from the AP view. Based on his clinical picture, ERCP was performed. The initial endoscopic image showed a clip encased in a stone at the ampulla (A). After wire cannulation past the stone, bile and pus began to flow out of the ampulla. A sphincterotomy was performed and the stone and clip were removed by balloon sweeps (B). Upon further review of the CT, a metal object was seen at the ampulla on sagital images (C)(box). Within 24 hours, the patient was back to his baseline and was discharged home. One similar case of a cholecystectomy clip causing obstruction and cholangitis was published in OVID (1).FigureFigureFigure

Surgical Clip as the Nidus for Common Bile Duct Stone Formation: A Very Rare Cause for a Common Condition

Surgical Clip as the Nidus for Common Bile Duct Stone Formation: A Very Rare Cause for a Common Condition

Gallbladder Motor Function in Patients with Different Thyroid Hormone Status

Hypothyroidism and hyperthyroidism are known to affect cholesterol metabolism, bile acid synthesis and bile content. There are previous studies reporting increased prevalence of gallstone and common bile duct stone formation in hypothyroidism. The aim of this study was to compare gallbladder (GB) motor function between euthyroid, hypothyroid and hyperthyroid subjects by conventional ultrasonography. Eighteen euthyroid, 14 hypothyroid and 20 hyperthyroid, age, sex and body mass index matched subjects were included in the study. Etiology of hypothyroidism comprised of thyroidectomy, Hashimoto's thyroiditis and previous radioactive iodine therapy. Hyperthyroid group included patients with toxic nodular goitre and Graves' disease. Patients who have diseases or are under drug treatment known to affect biliary function were not included in the study. Fasting and post-stimulus GB volumes were measured by real-time conventional ultrasonography and computer unit (Aloka UST-979, 3.5 mHz electronic convex probe, Japan). No significant differences were noted for fasting, post-stimulus GB volumes and GB ejection fraction between euthyroid, hypothyroid and hyperthyroid subjects. Measuring GB motility accurately is not straightforward because besides being not static during fasting, after a meal, intermittent emptying and refilling of GB occurs. Ultrasonography is affected by GB filling and measures "net" GB emptying. Although cumbersome, additional evaluation with cholescintigraphy which detects "absolute" GB emptying and is not affected by GB filling may provide complete assessment of motor function and may be more informative in evaluating subjects with different thyroid hormone status.

Piezoelectric extracorporeal shockwave lithotripsy for bile duct stone formation after choledochal cyst excision

We report a case of bile duct stones in which piezoelectric extracorporeal shockwave lithotripsy (ESWL) was highly effective for the clearance of stones. A 16-year-old girl, who had undergone excision of a choledochal cyst when she was 3 years old, presented a spiking fever and colic abdominal pain. Radiological investigations showed two large stones incarcerating to the proximal end of hepatico-jejunostomy anastomosis. Massive debris was also present in intrahepatic bile duct proximal to the anastomosis. She underwent piezoelectric ESWL with an EDAP LT02 lithotripter. An average of 40 min ESWL session was repeated at intervals of 2 or 3 days. Neither anesthetic nor sedative treatment was required. By the end of the sixth session, the stones incarcerated were fragmented and the debris in the intrahepatic bile duct was completely eliminated. We conclude that piezoelectric ESWL is a less invasive, effective and repeatable method, therefore, it could be a treatment of choice for bile duct stone formation after choledochal cyst excision.

A Common Bile Duct Stone formed by Suture Material after Open Cholecystectomy

The use of non-absorbable suture materials for cystic duct ligation after cholecystectomy can expose patients to the risk of recurrent stone formation in the common bile duct (CBD). However, in Korea suture materials have rarely been found to act as a nidus for common bile duct calculus formation. Recently, we experienced a case in which suture material, that had migrated from a previous cholecystectomy site into the CBD, probably served as a nidus for common bile duct stone formation. The stone was confirmed by endoscopic retrograde cholangiopancreatography (ERCP) and removed successfully using a basket. The authors report a case of surgical suture migration and discuss its subsequent role as a stone forming nucleus within the CBD in a patient who underwent open cholecystectomy; and include a review of the literature.

Low conjunction of the cystic duct with the common bile duct: does it correlate with the formation of common bile duct stones?

This study aimed to evaluate the accuracy of magnetic resonance cholangiography (MRC) in detecting variants of low cystic duct conjunction, which can be a source of confusion during surgery when unrecognized. All cases with both MRC and endoscopic retrograde cholangiography (ERC) indicating suspected common bile duct stones between January 1999 and January 2004 were retrospectively reviewed by investigators blinded to the final diagnosis. Assessment with ERC was regarded as the gold standard. The aim was to find a low conjunction of the cystic duct with the bile duct. The sensitivity and specificity of MRC were calculated in comparison with those for ERC. The cystic junction radial orientation was defined as lateral (insertion diagonally from the right), medial (insertion into the left side of the common hepatic duct), or posteroanterior (overlap of the junction with the bile duct in the posteroanterior view). A spiral cystic duct and a long parallel course were evaluated separately. Low insertion of the cystic duct was found on ERC in 66 of 622 patients (11%; 28 men and 38 women; mean age, 64.5 years). The sensitivity and specificity of MRC for detecting low cystic entrance were 100% (90.4% on an intention-to-diagnose basis and 100%, respectively). In 11 patients (16.6%), the radial orientation of the cysticohepatic junction could not be defined with MRC. The rate of correct MRC delineation was 95% for lateral (n = 21), 77% for medial (n = 26), and 74% for posteroanterior (n = 19) insertion of the cystic duct. The findings showed that MRC has good correlation with ERC with regard to the location and anatomic details of cystic duct insertion. Although this does not generate a separate indication for MRC before laparoscopic cholecystectomy, the anatomic information can be of additional use when MRC is clinically indicated in this setting.

Management of common bile-duct stones and associated gallbladder stones: surgical aspects

For many years, open exploration of the common bile duct has been the treatment of choice for patients with common bile-duct stones. During recent decades endoscopic sphincterotomy has gained wide acceptance as an effective and less invasive alternative. After sphincterotomy, subsequent (laparoscopic) cholecystectomy is warranted in patients with gallbladder stones. This chapter will discuss whether sphincterotomy should be performed prior to, during or after cholecystectomy, and will also address the question of whether single-stage treatment by laparoscopic cholecystectomy and laparoscopic bile-duct exploration is in fact preferable. The rate of recurrent choledocholithiasis after endoscopic biliary sphincterotomy can reach more than 20%. This review focuses on the risk factors--delayed bile-duct clearance and bactobilia--that may lead to recurrent primary bile-duct stone formation. Underlying altered bile composition (relative phospholipid deficiency) should be recognised in a subgroup of patients. Identification of these risk factors may significantly affect treatment policy.

An 80-Year-Old Lady With Choledocholithiasis In A Cystic Dilated Common Bile Duct: Cause Or Consequence?

Congenital cysts of the common bile duct (CBD) are rare. Mostly they are found in children and do not typically lead to the formation of common bile duct stones. It is uncertain whether primary CBD stones and acquired choledochal cysts exist. We present an 80-year-old woman presented with epigastric discomfort. Investigation revealed dilatation of the CBD with large concrements. The gallbladder showed no abnormalities and no stones. A cholecystectomy and CBD exploration with stone extraction were performed. Choledochal cysts are usually congenital and discovered in childhood. Congenital CBD cysts are known for their risk of forming a bile duct malignancy with an increasing incidence with age. Presentation at the age of 80 years has not been reported before. We believe that in this patient the underlying aetiology was a choledochal cyst-like dilatation acquired during life leading to stasis of bile and formation of primary CBD stones.

Intracorporeal electrohydraulic lithotripsy for intrahepatic bile duct stone formation after choledochal cyst excision

An 18-year-old girl who had undergone excision of a choledochal cyst and Roux-en-Y hepatico-jejunostomy at another hospital when 23 months old was referred to our department because of recurrent cholangitis. Radiological investigations showed stones lying in minimally dilated, right posterior intrahepatic bile ducts (IHBD). At laparotomy, the hepatico-jejunostomy site was incised, and a flexible endoscope inserted into the IHBD. Multiple stones packed in the IHBD were easily fragmented using an electro-hydraulic lithotripsy (EHL) device inserted through the endoscope, and removed. There were no EHL-related complications, and her postoperative progress was uneventful. She is currently well with no episodes of cholangitis after a follow-up period of 3 years. EHL is a simple, effective alternative method for removing IHBD stones after choledochal cyst excision. To the best of our knowledge, this is the first report of EHL being used to remove stones that developed in the IHBD after choledochal cyst excision.

Is bile flow reduced in patients with hypothyroidism?

Background. Disturbances in the sphincter of Oddi (SO) function may prevent normal bile flow and thus enhance the probability of common bile duct stone (CBDS) formation. We have previously shown increased prevalence of diagnosed hypothyroidism in CBDS patients, thyroxine (T4) -induced inhibition of the SO contractility both in animal and in human experiments ex vivo, and reduced bile flow to duodenum in hypothyroid rats. The aim of the present study was to investigate human biliary dynamics in relation to altered thyroid gland function. Methods. Eight female patients, 1 with diagnosed untreated hypothyroidism and 7 with total thyroidectomy performed due to thyroid cancer, were studied in hypothyroid stage and again after thyroxine replacement therapy in euthyroid stage, with quantitative 99mTc HIDA cholescintigraphy (QC), biliary ultrasonography, and serum determinations. Each patient served as her own control in the 2 stages of the study. Results. In QC, maximal uptake of 99mTc HIDA was not changed in hypothyroidism compared to euthyroidism. The first appearance of radioactivity to large bile ducts at the hepatic hilum remained unchanged in the 2 stages of the study. Hepatic clearance of 99mTc HIDA was decreased at 45 minutes (28% [11-38] vs 50% [33-54]; P =.028; median and range) and at 60 minutes (55% [28-80] vs 69% [61-79]; P =.028; median and range) and hilum-duodenal transit time increased by 31% compared to euthyroid stage. In US no changes were seen in gall bladder or bile ducts in the 2 stages of the study. Serum hypercholesterolemia was observed in the hypothyroid stage. Conclusions. We conclude that hypothyroidism may result in delayed emptying of the biliary tract, as studied with QC. In addition to the changes in bile composition and excretion rate suggested before to take place in hypothyroidism, according to the present study changes in biliary emptying also may be included in the probable causes for the increased prevalence of CBDS in hypothyroidism. This may be due to the absence of the prorelaxing effect of thyroxine on SO, which we have shown before to exist ex vivo. (Surgery 2003;133:288-93)

The role of juxtapapillary duodenal diverticula in biliary stone disease

Background: Duodenal diverticula are acquired lesions found more often in older patients; when located near the major duodenal papilla they are called juxtapapillary. The prevalence of juxtapapillary duodenal diverticula (JDD) in the general population is around 20%; they are often associated with biliary lithiasis. This study assessed the association between JDD and biliary stone disease, particularly choledocholithiasis. Methods: Four hundred fifty ERCPs were performed in 420 patients from 1995 through 1999. The results for 300 ERCPs that were performed in 285 patients for suspected biliary lithiasis were analyzed. Results: JDD were present in 21.42% of the 420 patients; most were found in patients in the eighth and ninth decades of life. Patients with JDD had bile duct stones alone more often than patients without JDD (44% vs. 24%). According to their features, these bile duct stones were characterized as mainly primary. The existence of JDD influences bile duct diameter irrespectively of the presence of bile duct stones. Conclusions: JDD are important causative factors in the formation of bile duct stones. (Gastrointest Endosc 2002;55:543-7.)

Mechanism of the Prorelaxing Effect of Thyroxine on the Sphincter of Oddi

Background: Disturbances in the function of sphincter of Oddi (SO) may prevent normal bile flow and thus enhance the probability of common bile duct stone (CBDS) formation. Previously, we have shown increased prevalence of hypothyroidism in CBDS patients. Methods: In animal (pig) experiments, thyroxine (T 4 ) and triiodothyronine have a specific inhibitory effect on SO contractility, which raises the possibility that the lack of this prorelaxing effect in hypothyroidism could, at least in part, explain the increased prevalence of CBDS. The aims of the present study were to investigate, whether human SO reacts similarly to T 4 , and to study the mechanisms of the T 4 prorelaxing effect. Results: We found that T 4 had similar inhibitory effects on both human and pig SO contractions. The T 4 effect was dosedependent, and maximum was observed in 30 min. The maximal prorelaxing effect was achieved with 0.1 nM T 4 concentration, the effect of the physiological T 4 concentration (0.01 nM) being about half of the maximal effect. Addition of α -adrenoceptor antagonist phentolamine, β -adrenoceptor antagonist propranolol, nitric oxide (NO)-synthesis inhibitor L-NAME, nerve conductance blocker tetrodotoxin, or cyclooxygenase inhibitor diclofenac did not affect the T 4 -induced inhibition of contraction. Addition of transcription inhibitor actinomycin D or translation inhibitor cyclophosphamide partially reversed the T 4 -induced inhibition of contraction. Addition of K + channel blocker glibenclamide totally reversed the T 4 -induced inhibition of contraction. In Western blotting, the thyroid hormone receptor (TR) antibody recognized 53 kDa and 58 kDa proteins, corresponding to β 1 and β 2 isoforms of TR, in the human SO tissue. Conclusions: We conclude that T 4 has a direct prorelaxing effect on human SO that expresses TR β 1 and β 2. This effect is mediated through a transcriptional mechanism that requires new mRNA and protein synthesis and subsequently leads to the activation of K + channels.

Common Bile Duct Stone Formation Induced by Tomato Skin Following Endoscopic Sphincterotomy

Common Bile Duct Stone Formation Induced by Tomato Skin Following Endoscopic Sphincterotomy

Molecular mechanisms of thyroid hormone action.

This brief review deals with the key trans- and cis-elements that are currently believed to participate in TH action at the transcriptional level. The reader is also referred to other recent reviews (53,54). In sum, there are multiple levels of complexity that make an understanding of the fundamental mechanisms of TH action difficult. However, the interactions of multiple TRs and TRAPS along with putative coactivators and ligands provide the cell with a wide range of biological responses. An appreciation of these phenomena will ensure insight into regulated gene expression in general, and the mode of action of TH in particular. While the field has progressed greatly since Jack Oppenheimer first described the nuclear binding of TH, there are "many more miles to go" for all of us, including Jack. We trust the journey will continue to be captivating.

Papillary Function of Patients with Juxtapapillary Duodenal Diverticulum Consideration of Pathogenesis of Common Bile Duct Stones

The papillary function of cholelithiasis patients with and without juxtapapillary duodenal diverticulum (JPDD) was examined manometrically. The papillary function was evaluated on the basis of dP(0.5), the pressure difference between the resting pressure and the perfusion pressure. Patients with a dP(0.5) less than 5 cm H2O were considered to have papillary dysfunction. In cholecystolithiasis patients the incidence of papillary dysfunction was significantly greater in those with JPDD than in those without JPDD (p less than 0.05). However, there was no significant difference in dP(0.5) between those with and without JDPP because of the small number of patients involved. Also, in patients with choledocholithiasis there was no difference in the papillary function between those with and without JPDD. All who had JPDD showed papillary dysfunction. From our results, JPDD is suspected to have an important role in causing papillary dysfunction or loss of papillary muscle tone. This dysfunction may be closely connected with the formation of common bile duct stones.

Biliary strictures as a cause of primary intrahepatic bile duct stones.

AbstractWe collected 51 cases of stricture in the upper portion of the biliary tract and discussed the pathogenesis and the clinical significance of the strictures. All 51 patients had congenital cystic dilatation of the common bile duct (CCDB): 2 had infant‐type cysts which involved the choledochus and/or the common hepatic duct, and 49 had adult‐type cysts which included the entire extrahepatic bile duct and/or the main intrahepatic bile ducts. Thirty‐five of the latter 49 had intrahepatic bile duct stones proximal to the stricture. Considering the location and the clinical features, the strictures may have been formed congenitally. Furthermore, adult‐type cysts of the common bile duct with strictures in the upper portion of the biliary tract are thought to be the basis for the formation of primary intrahepatic bile duct stones.

Biliary ascariasis: A common cause of biliary and pancreatic disease in an endemic area

We prospectively evaluated the incidence, clinical features, radiographic findings, and course of biliary and pancreatic disease caused by ascariasis in an endemic area in India. Ascariasis was an etiologic factor in 40 (36.7%) of the 109 patients studied who had biliary and pancreatic diseases. Disease was prevalent in adult women and was associated with recurrent biliary colic in 38 patients (95%), recurrent pyogenic cholangitis in 27 patients (68%), acalculous cholecystitis in 9 patients (23%), and pancreatic disease in 6 patients (15%). Vomiting of roundworms during biliary colic occurred in 19 patients (48%) and often led to confirmation of biliary ascariasis by direct visualization of the biliary tree. Endoscopic retrograde cholangiopancreatography was an excellent diagnostic tool and often demonstrated worms in the dilated common bile duct and intrahepatic ducts. The worms moved actively into and out of the biliary tree from the duodenum. Thirty-six (90%) patients recovered on symptomatic treatment followed by anthelmintic therapy once acute symptoms subsided. Surgery was needed in 4 patients, as the worms were trapped in the ducts and had led to the formation of common bile duct and intrahepatic duct stones with the worm fragment as the nidus.