Overview
Definition:
Choledocholithiasis refers to the presence of gallstones within the common bile duct (CBD)
Transductal exploration is a surgical technique involving direct visualization and clearance of the CBD through an incision in the duct itself, often performed during open or laparoscopic cholecystectomy.
Epidemiology:
Choledocholithiasis occurs in 10-20% of patients with symptomatic gallstone disease
It is more common in elderly females
Risk factors include rapid weight loss, obesity, pregnancy, and certain ethnicities
Prevalence increases with age and stone burden.
Clinical Significance:
Unresolved choledocholithiasis can lead to severe complications including cholangitis (fever, jaundice, RUQ pain - Charcot's triad), gallstone pancreatitis, biliary cirrhosis, and cholangiocarcinoma
Accurate diagnosis and complete stone clearance are crucial for preventing morbidity and mortality.
Clinical Presentation
Symptoms:
Epigastric or right upper quadrant (RUQ) pain
Jaundice, often progressing
Fever with chills, indicating cholangitis
Nausea and vomiting
Clay-colored stools and dark urine may suggest complete CBD obstruction.
Signs:
Jaundice (icterus)
Tenderness in the RUQ
Palpable gallbladder (Courvoisier's sign) if CBD is chronically obstructed
Fever, tachycardia, and hypotension in severe cholangitis (Reynolds' pentad)
Signs of pancreatitis may be present.
Diagnostic Criteria:
No single definitive criterion, but a combination of clinical, biochemical, and imaging findings is used
The presence of stones in the CBD confirmed by imaging, along with elevated liver enzymes (bilirubin, ALP, GGT, AST, ALT), strongly suggests choledocholithiasis.
Diagnostic Approach
History Taking:
Focus on history of gallstones, previous biliary colic, pancreatitis, or jaundice
Ask about constitutional symptoms like fever and weight loss
Assess for risk factors
Red flags include Charcot's triad or Reynolds' pentad, indicating acute cholangitis or severe pancreatitis.
Physical Examination:
A thorough abdominal examination focusing on the RUQ for tenderness, guarding, or a palpable mass
Assess for jaundice and signs of systemic illness (fever, tachycardia)
Check for ascites or hepatosplenomegaly.
Investigations:
Biochemical tests: Complete blood count (CBC), liver function tests (LFTs) including bilirubin (total and direct), alkaline phosphatase (ALP), gamma-glutamyl transferase (GGT), aspartate aminotransferase (AST), and alanine aminotransferase (ALT)
Elevated levels suggest cholestasis
Imaging modalities: Ultrasound (initial modality, sensitivity ~50-80% for CBD stones)
CT scan (better for pancreatitis and complications)
Magnetic Resonance Cholangiopancreatography (MRCP) (highly sensitive and specific for CBD stones and anatomy)
Endoscopic Ultrasound (EUS) (highest sensitivity for small CBD stones and difficult cases)
Direct cholangiography (during ERCP or surgery).
Differential Diagnosis:
Other causes of jaundice: Hepatitis, cirrhosis, pancreatic head mass, ampullary carcinoma
Other causes of RUQ pain: Peptic ulcer disease, appendicitis, cholecystitis, renal colic, hepatic abscess
Primary sclerosing cholangitis
Benign biliary strictures.
Management
Initial Management:
For suspected acute cholangitis: Broad-spectrum intravenous antibiotics (e.g., piperacillin-tazobactam, ceftriaxone + metronidazole)
Aggressive fluid resuscitation
Pain management
Urgent biliary decompression via ERCP or PTC if available and indicated.
Medical Management:
Antibiotics are the mainstay for cholangitis
Analgesics for pain control
Supportive care including hydration and electrolyte balance
Nutritional support if prolonged cholestasis or pancreatitis is present.
Surgical Management:
Indications for transductal exploration: Symptomatic choledocholithiasis confirmed by imaging, especially when ERCP is unsuccessful, contraindicated, or unavailable
It is often combined with cholecystectomy
Transductal exploration aims for complete stone clearance
Procedures include: Open Transcholedochal Exploration (T-tube drainage often used)
Laparoscopic Transcholedochal Exploration
Advantages: Definitive stone removal, allows for inspection of the entire duct
Disadvantages: Invasive, potential for bile leak, stricture formation, retained stones.
Supportive Care:
Post-operative monitoring for bile leak, cholangitis, pancreatitis, and bleeding
Pain management
Gradual resumption of diet
Physiotherapy as needed
T-tube care and flushing if used.
Transductal Exploration Details
Indications:
Failed or incomplete ERCP
Distal CBD stones not amenable to ERCP
Suspected stones in multiple CBD segments
Simultaneous cholecystectomy
Cost-effectiveness in certain healthcare settings.
Preoperative Preparation:
Optimizing patient's condition (hydration, correction of coagulopathy, antibiotic therapy for cholangitis)
Preoperative imaging (MRCP preferred for precise stone localization and anatomy)
Informed consent detailing risks and benefits.
Procedure Steps:
Usually performed after cholecystectomy
A longitudinal incision is made in the CBD (choledochotomy)
The lumen is explored digitally and visually (choledochoscope)
Stones are retrieved using stone baskets, irrigations, or scoops
Meticulous irrigation of the entire CBD is performed
Closure of the choledochotomy: Primary closure (if lumen is wide and no distal obstruction), repair with a T-tube (allows drainage and access for repeat cholangiography), or primary closure over a fine catheter
The cystic duct is usually ligated.
Postoperative Care:
Monitor vital signs and abdominal examination
Assess for signs of bile leak (bilious drain output, peritonitis)
Monitor LFTs
Pain management
Gradual advancement of diet
T-tube care: ensure patency, measure output, flush as per protocol
Early ambulation.
Complications:
Bile leak from the choledochotomy site
Retained CBD stones (may present later)
Bleeding from the duct or surrounding vessels
Cholangitis
Pancreatitis
Biliary stricture formation
Bile duct injury
Embolism (air or stone).
Complications
Early Complications:
Bile leak, bleeding, cholangitis, pancreatitis, wound infection, retained stones.
Late Complications:
Biliary stricture, recurrent choledocholithiasis, cholangiocarcinoma (rare association), gallstone ileus (if a large stone migrates).
Prevention Strategies:
Adequate visualization and exploration of the CBD
Complete stone clearance
Meticulous technique during choledochotomy closure
Judicious use of T-tube drainage
Postoperative cholangiography to confirm clearance if indicated
Prompt management of cholangitis and pancreatitis.
Prognosis
Factors Affecting Prognosis:
Severity of initial presentation (cholangitis, pancreatitis)
Completeness of stone clearance
Presence of underlying biliary strictures or malignancy
Patient's overall health status.
Outcomes:
With successful stone clearance and management of complications, the prognosis is generally good
Most patients experience relief of symptoms
Long-term complications like strictures can occur and may require further intervention.
Follow Up:
Regular follow-up with LFTs and ultrasound typically for 6-12 months postoperatively
Patients with a history of choledocholithiasis are at increased risk for recurrence and should be counselled regarding lifestyle modifications and early recognition of symptoms.
Key Points
Exam Focus:
Indications for surgical vs
endoscopic clearance of CBD stones
Complications of choledocholithiasis and their management
Details of transductal exploration technique and potential pitfalls
T-tube management.
Clinical Pearls:
Always consider choledocholithiasis in patients with gallstones and elevated LFTs or jaundice
MRCP is the gold standard for non-invasive imaging of CBD stones
A negative intraoperative cholangiogram does not completely rule out small stones
If a T-tube is used, ensure it remains patent and measure output.
Common Mistakes:
Incomplete stone clearance leading to recurrence or cholangitis
Aggressive manipulation of the CBD leading to pancreatitis or bleeding
Failure to diagnose or manage acute cholangitis promptly
Inadequate visualization during exploration.