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Obstructive jaundice

This 65 year-old lady presented with obstructive jaundice
1.  What is the investigation?
2.  What does it show?
3.  How should she be managed?

This 65 year-old lady presented with a two week history of jaundice, pale stools and dark urine.  Abdominal examination was unremarkable.  Her urine contained conjugated bilirubin.  Her liver function tests showed an obstructive picture.  An abdominal ultrasound scan showed stones within the gall bladder and a common bile duct (CBD) dilated to 18mm. The clinical picture was that of obstructive jaundice secondary to gallstones.  She proceeded to endoscopic retrograde cholangiopancreatography (ERCP).  Two large stones were identified within the bile duct.  An endoscopic sphincterotomy was performed and an attempt to extract the stones with a balloon catheter and Dormia basket failed.  A biliary stent was inserted. A subsequent attempt to crush the stones with a mechanical lithotripter also failed.  She proceeded to an open cholecystectomy and exploration of her CBD.  The stones were extracted and a T-tube inserted.  A subsequent T-tube cholangiogram performed,10 days postoperatively, showed no retained stones and the tube was removed without complication.T-tube cholangiogram showing no retained stones and free flow of contrast into the duodenum

Common bile duct stones are seen in approximately 15% of patients with gallstones.  Most bile duct stones are believed to form in the gallbladder and to migrate to the bile duct.  Some stones may form de novo within the bile duct.  These are often softer and more friable than gall bladder calculi.  Many small bile duct stones are asymptomatic and, if small, may pass spontaneously.  If bile duct stones are symptomatic, they present with either obstructive jaundice, acute pancreatitis or acute cholangitis. 

When open cholecystectomy was widely practiced, an on-table cholangiogram was often performed to exclude CBD stones.  With the advent of laparoscopic cholecystectomy, the pre-operative prediction of common bile duct stones has attracted much attention in order to perform ERCP selectively on patients at high risk of CBD stones and to avoid further investigation in other patients.  The presence of jaundice, a CBD diameter of greater than 12 mm and an increased alkaline phosphatase is 90% predictive of the presence of bile duct stones.  If there is no history of jaundice and both the  CBD diameter and alkaline phosphatase are normal then the risk of a CBD stone is 0.2%.

ERCP is the 'gold standard' investigation for the detection of CBD stones.  It has the advantage of also being a potentially therapeutic procedure.  It is, however, an invasive procedure with attendant morbidity.  Overall, approximately 5% of patients develop complications.  The mortality assocaited with procedure is approximately 1%.  About 1% of patients develop pancreatitis and 5% of those who undergo a sphincterotomy develop late papillary stenosis.  With the risk associated with ERCP, interest has been shown in the non-invasive detection of CBD stones.  Intravenous infusion cholangiography has an inadequate sensitivity for the detection of bile duct stones.  Recently, Magnetic resonance cholangiopancreatography has been shown to have a sensitivity and specificity similar to that of ERCP.  It has the potential to reduce the number of negative pre-operative ERCPs performed.

Recent papers

Demartines N,  Eisner L,  Schnabel K,  Fried R,  Zuber M,  Harder F.  Evaluation of magnetic resonance cholangiography in the management of bile duct stones. Arch Surg 2000;  135:  148-152.

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