Diagnosis Of Choledocholithiasis Research Articles

English

BACKGROUND: Choledocholithiasis is a complication of gallbladder stones; only in a minority of the patients they arise de novo in the bile ducts. In the present study, we have attempted to enumerate the demographic characteristics, various modes of clinical presentation, diagnostic tests, management and complications of the patients with choledocholithiasis. METHODS: A prospective study was conducted from October 2009 to September 2011 (24 months including follow-up period) in patients diagnosed to have choledocholithiasis. Patients with intra-hepatic stones and biliary stricture were excluded from the study. Demographic characteristics, various modes of clinical presentation, investigations, management and complications of the patients with choledocholithiasis were studied. A total of 31 patients with a diagnosis of choledocholithiasis are included in this study. The patients were divided into two groups -Open Surgery (CBD exploration and cholecystectomy) and ERCP followed by Laparoscopic Cholecystectomy. RESULTS: Right hypochondrial pain was the most common clinical manifestation followed by jaundice and fever. Serum Bilirubin and Alkaline Phosphatase were in most cases. Ultrasonography was most important imaging modality failing which CT or MRI scans were indicated. ERCP with Endoscopic Sphincterotomy (ES) was done in 22 patients and was successful in 19 of them. 3 failures were due to impacted stones. 12 patients underwent open CBD exploration with cholecystectomy. Incidence of complications were significantly more and also the duration of Hospital stay was more in those who underwent open surgery. CONCLUSION: Ultrasonography has a sensitivity of 70.96% in detecting CBD calculi. Routine use of MRCP and CT is not required. ERCP with Endoscopic Sphincterotomy followed by laparoscopic cholecystectomy can be used for the treatment of CBD calculi. Complications are more in patients who undergo open surgery. There is a significant decreased mean hospital stay in patients who undergo endoscopic treatment.

Choledocholithiasis in African American and Hispanic Patients: A Comparison Between Painless Presentation and Classical Biliary Pain with Regards to Clinical Manifestations and Outcomes

Choledocholithiasis (CDL) usually presents with biliary pain. Painless CDL is also known to occur, especially in the elderly. The purpose of this study is to determine whether the mode of presentation (painful vs. painless) influences the clinical course and outcomes of CDL in African American and Hispanic patients. Ten years of admission and discharge records (January 1998-December 2007) were reviewed retrospectively, yielding 527 community hospital patients, aged 23-97 years, with the final diagnosis of CDL. Patients with painless presentation had higher odds of having comorbidities compared to patients presenting with pain. However, patients who presented with biliary pain were predominantly younger (mean age 34 years), and 59% were Hispanic females (p = 0.001). In our study painless CDL was associated with higher morbidity and mortality.

総胆管結石症に対するCT-cholangiographyの基礎的,臨床的検討

総胆管結石症に対するCT-cholangiographyの基礎的,臨床的検討

Predicting complicated choledocholithiasis

IntroductionManagement of choledocholithiasis and its complications is variable and often requires transfer to a specialty facility. This study links patient-specific characteristics with the outcome measure of complicated choledocholithiasis to identify high-risk patients who may require expedited treatment or transfer to a higher level of care. Materials and methodsPatients with a discharge diagnosis of choledocholithiasis (CDL) were identified from the 2009 Nationwide Inpatient Sample (NIS). Patient characteristics were identified associated with the primary outcome measure of complicated choledocholithiasis (cCDL), defined as acute pancreatitis or cholangitis during the admission for CDL. Predictors of mortality were also evaluated. Analysis was performed using complex-sample univariate and adjusted analyses. ResultsWe identified 123,990 discharges with a diagnosis of CDL. The overall incidence of CDL was 314 per 100,000 NIS discharges. Forty-one percent of CDL discharges were for cCDL (acute pancreatitis 31%, cholangitis 12%). Risk factors for cCDL included age (risk increased 0.8% per year), male gender (odds ratio [OR] 1.2, 95% confidence interval [CI] 1.1–1.2), alcohol abuse (OR 1.5, CI 1.3–1.8), diabetes (OR 1.1, CI 1.0–1.2), hypertension (OR 1.1, CI 1.0–1.2), obesity (OR 1.2, CI 1.1–1.3), nonelective admission (OR 2.3, CI 2.0–2.6), and Asian/Pacific Islander race/ethnicity (OR 1.2, CI 1.0–1.5). Patients with cCDL had increased odds of mortality (OR 1.5, CI 1.2–2.0). ConclusionsIncreased age, nonelective admission, and specific comorbid conditions are associated with cCDL, which has increased mortality. These factors can be used to identify patients needing timely access to treatment or transfer to a higher level of care.

Diagnostic Value of Dynamic Contrast-Enhanced Magnetic Resonance Imaging in the Evaluation of the Biliary Obstruction

Purpose. In this study, our purpose was to investigate the diagnostic efficacy of the dynamic contrast-enhanced magnetic resonance imaging (MRI) method in the patients with bile duct obstruction. Materials and Methods. 108 consecutive patients (53 men, 55 women, mean age; 55.77 ± 14.62, range 18–86 years) were included in this study. All the patients underwent conventional upper abdomen MRI using intravenous contrast material (Gd-DTPA) and MRCP in 1.5 Tesla MRI scanner. MRCP images were evaluated together with the T1 and T2w images, and both biliary ducts and surrounding tissues were examined for possible pathologies that may cause obstruction. Results. MRI/MRCP findings compared with final diagnoses, MRI/MRCP in the demonstration of bile duct obstruction sensitivity 96%, the specificity 100%, and accuracy 96.3%, in the detection of presence and level of obstruction, the sensitivity 96.7%, specificity 100%, and accuracy 97.2%, in the diagnosis of choledocholithiasis, the sensitivity 82.3%, specificity 96%, and accuracy 91.7%, and in the determination of the character of the stenosis, sensitivity 95.6%, specificity 91.3%, and accuracy 94.5% were found. Conclusion. The combination of dynamic contrast-enhanced MRI and MRCP techniques in patients with suspected biliary obstruction gives the detailed information about the presence of obstruction, location, and causes and is a highly specific and sensitive method.

To ‘gram or not’? Indications for intraopertive cholangiogram

The purpose of this study was to evaluate the current practice patterns and results for use of intraoperative cholangiogram (IOC) during laparoscopic cholecystectomy (LC). We performed a retrospective review of all patients who underwent LC between January 1, 2005 and December 31, 2009. Data variables included: preoperative laboratory and radiographic studies, indication for and findings of IOC, and perioperative management of choledocholithiasis and retained common bile duct (CBD) stones. There were 1,308 patients who underwent LC by 23 surgeons, of whom 266 also had an IOC (20%) performed. The majority had ultrasonography performed, 242 had an abdominal compute tomography (CT) scan, and 129 patients had a hepatobiliary iminodiacetic acid (HIDA) scan. Indications for an IOC included: diagnosis of choledocholithiasis or gallstone pancreatitis (n = 116), abnormal liver function tests (n = 187), and a dilated CBD ≥ 10 mm (n = 182). Of the 266 IOCs, 36 patients (13.5%) had a CBD stone with the majority (n = 26; 72%) having normal preoperative imaging studies. Only 6 patients (17%) with a CBD calculi on IOC underwent successful clearance of the calculi at the time of LC. Twenty-nine of the remaining 30 patients with a retained calculus on IOC underwent postoperative endoscopic retrograde cholangiopancreatography (ERCP) with extraction of the calculi. Of the 1,042 LCs performed without an IOC, 31 patients (3%) were diagnosed with a retained stone managed successfully by ERCP. Our data reveals that the selective use of IOC is helpful in diagnosing and clearing CBD calculi, that the use of preoperative CBD size aids in selecting patients for IOC, and that choledocholithiasis identified with IOC or after discharge can be managed successfully with ERCP.

Diagnostic accuracy and therapeutic impact of endoscopic ultrasonography in patients with intermediate suspicion of choledocholithiasis and absence of findings in magnetic resonance cholangiography

endoscopic ultrasonography (EUS) and magnetic resonance cholangiography (MRC) are the elective tests in the diagnosis of choledocholithiasis. MRC is best accepted by patients, but its sensitivity might decrease in the evaluation of microlithiasis. to evaluate the diagnostic accuracy and therapeutic impact of EUS in a prospective cohort of patients with intermediate suspicion of choledocolithiasis and no findings in MRC (normal MRC). during a period of 24 months, all the patients with clinical intermediate suspicion of choledocholithiasis and normal MRC were included. Sensitivity, specificity, diagnostic accuracy, positive predictive value (PPV) and negative predictive value (NPV) of MRC and EUS were compared, and so their impact in the management of these patients. seventy six patients were evaluated (lithiasis in 30% of them). Sensitivity and diagnostic accuracy of EUS (100%, 92%) were significantly higher than MRC values (0%, 70%) (p < 0.05). EUS findings (suspicion of choledocholithiasis) favored a significant change in therapeutic attitude (therapeutic ERCP was performed) in 38% of the patients (in which MRC had ruled out the presence of choledocholithiasis, and so, ERCP had not been performed) (p < 0.05). EUS allows the diagnosis of lithiasis in approximately 1/3 of patients with intermediate suspicion of choledocholithiasis and normal MRC. EUS findings involve a significant change in the management of these patients; this supports the use of EUS in clinical practice.

Diagnosis of choledocholithiasis

Diagnosis of choledocholithiasis

Biliary cannulation facilitated by endoscopic clip assistance in the setting of intradiverticular papilla

Endoscopic cannulation of the biliary tract may be challenging in cases with juxtapapillary, duodenal diverticula. A 70-year old woman admitted to the hospital with the diagnosis of choledocholithiasis and acute cholangitis. She was placed on antibiotic treatment and parenteral fluid resuscitation. On endoscopic retrograde cholangiopancreatography, the papilla could not be cannulated because of the duodenal diverticulum. Various attempts at biliary cannulation failed. Endoscopic clips were used for evertion and fixation of a partially everted papilla from the diverticulum and for securing it in an orientation that allowed direct cannulation of the biliary tree. Cholangiography demonstrated multiple calculi within the choledochus. She was discharged from the hospital on the 9th day following endoscopic retrograde cholangiopancreatography in good condition. With this report, we aimed to remind physicians that the clip assisted method is a safe and effective technique for pancreatic and/or biliary cannulation, and should be preferred in patients in whom cannulation is extremely difficult due to large periampullary diverticula..

Preoperative diagnosis of choledocholithiasis: the role of MRCP

Biliary imaging has changed as a result of technological advances, but the timing and modality of preoperative biliary tree imaging is controversial. An ideal imaging modality would be risk free and have a high sensitivity and specificity, a role fulfilled by magnetic resonance cholangiopancreatography (MRCP).

Spontaneously removed endobiliary J stent drainage after laparoscopic common bile duct exploration

Given the limitations and risks associated with current treatments for common bile duct (CBD) stones, the authors placed a spontaneously removed endobiliary J stent in the distal CBD to decompress the biliary tract and performed a primary closure of the CBD after laparoscopic common bile duct exploration (LCBDE). In this study, 10 of 14 patients with a diagnosis of choledocholithiasis were successfully treated using LCBDE. After extraction of the CBD stones using a choledoscope, a J-shaped stent was placed into the distal CBD as an internal drainage. The J stent was fixed with a rapid absorbable suture at the choledochotomy, which was closed by primary suture. The procedures for all 10 patients were successfully completed. No complications related to placement of the endobiliary J stents were observed postoperatively. None of the patients reported discomfort, and the J stents passed spontaneously 2 to 3 weeks after discharge. Spontaneously removed endobiliary J-stent drainage is a safe and effective surgical technique that allows for straightforward postoperative management after LCBDE.

The Incidence of Choledocholithiasis in a Community Setting

Introduction: The incidence of obesity related disorders such as diabetes, hyperlipidemia, and coronary artery disease are increasing. Cholelithiasis is an obesity related disorder, with an annual incidence which is estimated to be 1,000,000. Choledocholithiasis is associated with cholelithiasis and therefore should be increasing in incidence. We looked at the incidence of choledocholithiasis in a community setting. Material and Methods: All admissions, outpatient and inpatient, with a diagnosis of choledocholithiasis, cholangitis, or gallstone pancreatitis during the years 1996-2006 were included. All Endoscopic Retrograde Cholangiopancreatographies from the same time period were reviewed and all subjects with the above diagnosis included. The results were compared to overall admissions from 1996-2006. Results: Mean age of subjects was 55. Females represented 63% of cases, 37% male. Racial breakdown was 63% Caucasian, 28% African American and 9% Hispanic. Subjects meeting inclusion criteria were 42 in 1996 and 152 in 2006. Cases relative to admissions were 2/1000 admissions in 1996 and 5.1/1000 in 2006, p < .001. Increases in cases were seen in 7 of the 10 years. Conclusions: In this community setting there was a dramatic rise in the cases of choledocholithisis over a ten year period. This could reflect referral bias, and increased awareness of the disease. The substantial increase could also reveal a real increase in the incidence of choledocholithiasis. Further studies are needed to assess whether this is an isolated phenomenon or indicative of a nationwide trend as the answer could impact greatly manpower needs for ERCP trained physicians.

Avaliação de complicações relacionadas à CPRE em pacientes com suspeita de coledocolitíase

OBJETIVO: Determinar os fatores preditivos de complicações da colangio-pancreatografia retrógrada endoscópica (CPRE) nos doentes com suspeita diagnóstica de coledocolitíase. MÉTODO: Os dados foram coletados retrospectivamente durante o período de agosto de 1999 a janeiro 2005. Foram incluídos os doentes com suspeita diagnóstica de coledocolitíase submetidos à CPRE internados na Santa Casa de Misericórdia de São Paulo. Os doentes com neoplasia de vias biliares ou de pâncreas foram excluídos. Foram avaliados: o sucesso do procedimento, as complicações como pancreatite, sangramento, colangite, perfuração, vômitos, hiperamilasemia e em quais situações estas complicações se desenvolveram. Os testes t de Student, Qui-quadrado e o teste exato de Fisher foram empregados para análise estatística, considerando-se p&lt; 0,05 como significativo. RESULTADOS: Cento e setenta oito doentes foram incluídos, sendo 52 homens e 126 mulheres com média etária de 54,3 + 19,3. A CPRE confirmou o diagnóstico de coledocolitíase em 124 doentes (69,7%), obtendo sucesso no tratamento endoscópico em 92 casos (74,2%). As complicações foram detectadas em 19 doentes (10,7%), com seis casos de pancreatite aguda (3,4%), quatro (2,2%) que tiveram sangramento durante o procedimento endoscópico, dois (1,1%) doentes que desenvolveram colangite, um (0,6%) com perfuração duodenal, quatro (2,2%) com vômitos sem pancreatite e dois (1,1%) com complicações clinicas. A cateterização do ducto pancreático durante a realização do procedimento endoscópico esteve associada com o desenvolvimento de pancreatite aguda (p=0,004). CONCLUSÃO: A cateterização do pâncreas durante a CPRE constituiu um fator preditivo para o desenvolvimento de pancreatite aguda pós-CPRE.

Endoscopic Ultrasonography Versus Other Diagnostic Modalities in the Diagnosis of Choledocholithiasis

Until recently, endoscopic retrograde cholangiopancreatography (ERCP) has been considered the gold standard for the diagnosis of and therapy in patients with suspected choledocholithiasis. However, the non-negligible complication rate of diagnostic and therapeutic ERCP has led investigators to identify different noninvasive diagnostic modalities. Endoscopic ultrasonography has been proved to be of great sensitivity (up to 97%) in the diagnosis of even tiny stones that can be easily masked by contrast medium during ERCP, without any procedure-related complications and with a negative predictive value reaching 100%, meaning that it can accurately and safely identify patients with choledocholithiasis, thereby avoiding inappropriate instrumental exploration of the common bile duct.

Impact of operators experience on value of high-resolution transabdominal ultrasound in the diagnosis of choledocholithiasis: A prospective comparison using endoscopic retrograde cholangiography as gold standard

Impact of operators experience on value of high-resolution transabdominal ultrasound in the diagnosis of choledocholithiasis: A prospective comparison using endoscopic retrograde cholangiography as gold standard

Accuracy of MDCT in the Diagnosis of Choledocholithiasis

Our purpose was to evaluate the diagnostic performance of contrast-enhanced and unenhanced MDCT, performed for various indications, in detecting choledocholithiasis. Unenhanced and contrast-enhanced MDCT images, interpreted in PACS workstations with axial images, are moderately sensitive and specific for showing choledocholithiasis.

ERCP and MRCP in the diagnosis of choledocholithiasis and pancreatic-biliary tumors: A retrospective analysis

ERCP and MRCP in the diagnosis of choledocholithiasis and pancreatic-biliary tumors: A retrospective analysis

Impact of the operator's experience on value of high-resolution transabdominal ultrasound in the diagnosis of choledocholithiasis: A prospective comparison using endoscopic retrograde cholangiography as the gold standard

Objective. Transabdominal ultrasound (US) is the most frequently used imaging method for the diagnosis of choledocholithiasis. The aim of this prospective study was to evaluate the diagnostic accuracy of high-resolution US in the diagnosis of common bile duct stones depending on the operator's experience and in comparison with endoscopic retrograde cholangiography (ERC) as the gold standard. Material and methods. From April 2003 through November 2004, 126 patients referred because of clinically and biochemically suspected common bile duct stones were included in the study. Two patients were excluded because they refused to undergo ERC. Consequently, the study comprised 124 patients (86 F, 38 M, mean age 63.2 years, range 21–91 years). High-resolution US was performed (2–5 MHz sector scanner; Siemens Elegra, Erlangen, Germany) by operators who were unaware of the results of other imaging procedures. The definitive diagnosis was established by means of ERC. Results. Thirty-five out of 124 patients were investigated by experienced examiners. Twenty-seven of 35 patients (77%) were found to have stones at ERC. Bile duct stones were correctly found by US in 22 out of 27 patients (sensitivity 82%, 95% CI: 63–92). Of the 8 patients without stones at ERC, one false-positive diagnosis was made with US (specificity 88%, 95% CI: 53–98). Correct diagnoses were made in 29 out of 35 (accuracy 83%, 95% CI: 67–92) patients investigated by experienced examiners. Eighty-nine out of 124 patients were investigated by less-experienced examiners. Fifty-four of 89 patients (61%) were found to have stones at ERC. Choledocholithiasis was found correctly in only 25 out of 54 patients (sensitivity 46%, 95% CI: 34–59). Of the 35 patients without stones at ERC, three false-positive diagnoses were made with US (specificity 91%, 95% CI: 78–97). In conclusion, correct diagnoses were observed in 57 of 89 patients (accuracy 64%, 95% CI: 54–73) investigated by less-experienced examiners (p<0.05 in comparison with the results of experienced examiners). Conclusions. High-resolution US carried out by experienced examiners has a high diagnostic accuracy in the diagnosis of choledocholithiasis. Therefore, good training and continued experience are prerequisites for successful sonographic detection of bile duct stones using US. Under these conditions, further expensive and invasive methods such as ERC, magnetic resonance cholangiopancreatography and endoscopic ultrasonography may not be necessary in cases with a clear sonographic diagnosis.

Usefulness of Endoscopic Ultrasound in Patients at High Risk of Choledocholithiasis

BackgroundEndoscopic retrograde cholangiopancreatography (ERCP) has been considered the nonsurgical gold standard for the diagnosis and treatment of choledocholithiasis (CDL). Complications include a 0.1% to 1.3% mortality rate and a 5% to 19% morbidity rate, including a reported 1.8% to 6.7% incidence of postprocedure pancreatitis. Twenty-seven percent to 67% of ERCPs done for suspected choledocholithiasis ultimately have negative results. Endoscopic ultrasound (EUS) has been proposed as an alternate means of diagnosing choledocholithiasis that may eliminate the need for ERCP and its associated morbidities in certain patients.MethodsRetrospective chart review identified 30 patients who underwent EUS with or without ERCP for suspected choledocholithiasis. Reports of all procedures performed were obtained and data were collected on all biliary abnormalities identified on both EUS and ERCP. Results: Pancreaticobiliary abnormalities were identified in 27 of 30 patients (90%) at EUS. Most common diagnoses included CDL (n = 9, 30%), biliary sludge (n = 11, 37%), pancreatitis (n = 8, 27%), and cholelithiasis (n = 7, 23%). Subsequent ERCP was performed in 14 patients (47%). Indications included a diagnosis of CDL by EUS (n = 9) and abnormal liver function tests (n = 5). CDL was identified in 5 of 14 patients (36%), and microlithiasis/biliary sludge was identified in an additional 5 patients (36%). In 4 patients, CDL was identified by EUS but not by ERCP. ERCP did not identify any new cases of CDL after EUS: of 21 patients without evidence of CDL on EUS, none were subsequently shown to have CDL or to develop any complications related to common duct stones.ConclusionsEUS is an effective method of diagnosing CDL. It demonstrates both a high sensitivity and specificity for identifying common bile duct stones. Its use as a screening modality in patients suspected of having CDL may allow more selective use of ERCP.

Modificação técnica da coledocoduodenostomia látero-lateral - análise dos resultados

OBJETIVO: Avaliar se a oclusão do colédoco distal se mantém no decorrer do tempo, nos pacientes submetidos a coledocoduodenostomia látero lateral com oclusão do colédoco distal. MÉTODO: Foram analisados 14 doentes submetidos à coledocoduodenostomia látero-lateral modificada por Fava, para prevenir a "Síndrome do Colédoco Distal", tratados de coledocolitíase não complicada. Os doentes avaliados encontravam-se em pós-operatório que variou de três meses até dez anos após a derivação bílio-digestiva. Os doentes foram analisados do ponto de vista clínico através da classificação de Visick, submetidos à dosagem de transanimases (AST e ALT), enzimas canaliculares (gama-GT e fosfatase alcalina), bilirrubinas e ao exame de colangioressonância. Os doentes que apresentaram alguma alteração nos exames citados, foram submetidos à CPRE para avaliação definitiva da via biliar, identificação e tratamento de eventuais complicações da coledocoduodenostomia RESULTADOS: Em 11 doentes (78,6%) foi identificada abertura da oclusão do colédoco distal. Quatro doentes com menos de um ano de pós-operatório; quatro, entre um e cinco anos; e três doentes com mais de cinco anos de coledocoduodenostomia. Três doentes (21,4%) apresentaram "Sump Syndrome" no período de três meses, nove meses e oito anos de pós-operatório respectivamente, sendo tratados com sucesso através de papilotomia endoscópica. CONCLUSÕES: Nos doentes tratados de coledocolitíase não complicada a oclusão do colédoco distal na coledocoduodenostomia modificada por Fava et al, não se mantém patente no decorrer do tempo, não evitando o aparecimento da "Síndrome do Colédoco Distal".