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dilated cbd treatment

You may also need to drain the fluid in your bile duct and find the cause of any blockage. In most cases, this is done by a method called ERCP (endoscopic retrograde cholangiopancreatography).

Cholangitis is an inflammation of the bile duct system. The bile duct system carries bile from your liver and gallbladder into the first part of your small intestine (the duodenum).

Each person’s symptoms may vary, and may be non-specific or severe, including:

  • Ultrasound (also called sonography). This test creates images of your internal organs on a computer screen using high-frequency sound waves. It is used to see organs in your belly such as the liver, spleen, and gallbladder. It also checks blood flow through different vessels. It can be done outside the body (external). Or it may be done inside the body (internal). If internal, it is called an endoscopic ultrasound (EUS).
  • CT scan. A CT scan may be done with a dye that is swallowed or injected through an IV. This will show the abdomen and pelvis including the bile drainage area. It can help determine why there is a blockage.
  • Magnetic resonance cholangiopancreatography (MRCP). This test is used to look for any problems in your abdomen. It can show if there are gallstones in your bile duct. The test is done from outside your body. It does not involve putting a tube (endoscope) into your body. It uses a magnetic field and radio frequency to make detailed pictures.
  • ERCP (endoscopic retrograde cholangiopancreatography). This is used to find and treat problems in your liver, gallbladder, bile ducts, and pancreas. It uses X-ray and a long flexible tube with a light and camera at one end (an endoscope). The tube is put into your mouth and throat. It goes down your food pipe (esophagus), through your stomach, and into the first part of your small intestine (the duodenum). A dye is put into your bile ducts through the tube. The dye lets the bile ducts be seen clearly on X-rays. If required, this procedure can also help open up your bile ducts.
  • Percutaneous transhepatic cholangiography (PTC). A needle is put through your skin and into your liver. Dye is put into your bile duct so that it can be seen clearly on X-rays. This procedure can also be used to open up the bile ducts if your physicians are unable to do it internally with an ERCP.

How is cholangitis diagnosed?

The infection causes pressure to build up in your bile duct system, which can spread to other organs of the bloodstream if it is not treated.

You may also have imaging tests including:

The pain from cholangitis can feel a lot like the pain from gallstones.

What causes cholangitis?

If you have had gallstones you are at greater risk for cholangitis. Other risk factors include:

In most cases cholangitis is caused by a blocked duct somewhere in your bile duct system. The blockage is most commonly caused by gallstones or sludge impacting the bile ducts. Autoimmune disease such as primary sclerosing cholangitis may affect the system.

Dilated cbd treatment

Of 101 patients analyzed, 32 had moderate or severe cholangitis as the indication for emergent drainage, and the remaining 69 did not. Patients who required emergent drainage were more likely to have gallstones (P = 0.029), dilated CBD (> 10 mm) (P = 0.004) and larger CBD stones (P = 0.019). By multivariate analysis, CBD dilation was the only significant differentiating clinical characteristic of the patients who required emergent drainage (OR = 3.75, 95% CI: 1.41-9.96, P = 0.008). Of the 35 patients with silent bile duct stones, eight required emergent endoscopic drainage during the waiting period. CBD dilation was also the only significant risk factor for the development of moderate or severe cholangitis among patients with silent bile duct stones (OR = 10.18, 95% CI: 1.09-94.73, P = 0.042).

Results

Acute cholangitis ranges from mild forms that respond to medical therapy to severe forms that lead to septicemia, a potentially lethal condition requiring emergent drainage of the bile duct [1, 2]. The major cause of acute cholangitis is presence of common bile duct (CBD) stones. It has been reported in the United States that approximately 70% of patients with acute cholangitis are able to achieve improvement with medical therapy alone [3]. However, the remaining cases do not respond to medical treatment and the clinical manifestations and laboratory data do not improve. Such cases may progress to sepsis with or without organ dysfunction and require appropriate management that includes intensive care, organ-supportive care and emergent biliary drainage, in addition to medical treatment. It has also been reported that the mortality rate due to acute cholangitis was up to approximately 10% despite appropriate antimicrobial therapy and biliary drainage [4, 5].

Conclusions

Some patients with common bile duct (CBD) stones develop cholangitis requiring drainage, while others do not. The aims of this study were to elucidate the clinical differences among patients with CBD stones who required and did not require emergent drainage, and to identify risk factors for the development of cholangitis requiring emergent drainage in patients with silent CBD stones.

Dilated cbd treatment

Completion choledochoscopy is performed showing no residual stones. Next, trans-cystic IOC is repeated to check for the absence of retained CBD stones. Once a negative IOC is obtained, the CD is closed with suture and titanium clips.

Our choice to perform a transverse choledochotomy rather than a longitudinal one is because a transverse incision interrupts less ductal arterioles and its suture reduces the risk of ischemia. Should a larger stone be present, a transverse incision cannot be extended. Instead, with a longitudinal choledochotomy, there may be tendency on the part of the surgeon towards extending the ductal incision when large stones are present, and its subsequent suture narrows the CBD which gains an hourglass configuration, with consequent risk of bile stasis and recurrent primary brown stones formation.

Step 4—completion of trans-cystic exploration

The procedure of choice for CBD stones treatment is still debated (3). In many centers, endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES) before or after LC (two-stage endo-laparoscopic management) is standard practice, replacing traditional open choledocholithotomy and cholecystectomy (3-7). Single-stage laparoscopic management of gallstones and CBD stones has more recently been introduced, showing equivalent outcomes to the two-stage approach in randomized controlled trials, with a shorter hospital stay (1,3,4,7). Moreover, the two-stage endo-laparoscopic management of CBD stones may be associated with higher additional procedures rate and related increased costs as well as increased recurrent ductal stones rate, as compared to single-stage laparoscopic management (3,5,6,8).

After closure of the CD, retrograde cholecystectomy is performed, and the gallbladder is removed with a specimen retrieval bag.

Step 5—cholecystectomy and gallbladder extraction

The indications are: ductal stones having a size larger than the size of the CD, multiple CBD stones (>5), low and medial junction between CD and CBD, common hepatic duct (CHD) stones. A prerequisite is the presence of a dilated CBD of at least 8–10 mm in diameter. Laparoscopic choledochotomy requires laparoscopic suturing experience and it may therefore be more difficult as compared to the trans-cystic approach, but CBD exploration is easier, including exploration of the CHD which may be difficult or impossible to explore trans-cystically.