Choledocholithiasis

Anatomy and Physiology of the Gallbladder The gallbladder is a blind-ended sac which hangs on the under surface of the liver and it is attached to the main bile duct by a small tube called the cystic duct. There are many variations in the anatomy of the area where the cystic duct joins the bile duct. Physiology The function of the gallbladder is to store bile and to concentrate it as well. Food entering the duodenum, fats in particular, leads to the release of the hormone cholecystokinin. This stimulates the gallbladder to contract thus releasing bile into the duodenum. Concentrated bile helps to emulsify fats in the process of digestion. The liver produces bile which aids in the digestion of fats. The bile travels through tiny canals which eventually drain through the common bile duct into the small intestine. The gallbladder stores excess bile that is not immediately needed for digestion.

Common Bile Duct Stone Choledocholithiasis is a disease of the common bile duct. The common bile duct forms at the junction of the cystic duct (from the gallbladder) and the common hepatic duct (from the liver). It drains bile into the duedenum (the first part of the small intestine). Gallstones (cholesterol stones or pigment stones) form in the gallbladder over many years. They can sometimes travel into the common bile duct, causing a blockage. If the common bile duct is blocked, this then obstructs the whole of the biliary drainage system as opposed to a blockage further up. Hence there is nowhere for the bile to go but up and the patient becomes jaundiced since certain waste products (bilirubin) are absorbed back into the blood stream. Furthermore there can be potentially fatal complications of infection of the biliary tree (cholangitis) and acute pancreatitis. Risk Factors for Common Bile Duct Stone The predisposing factors for common bile duct stones are the same as for Gallstones. Risk factors for cholesterol stones include: high serum cholesterol leves, increased age, female sex, obesity, rapid weight loss, the contraceptive pill, and total parenteral nutrition. Risk factors for pigment stones include chronic hameolysis (red blood cell breakdown) hereditary spherocytosis, sickle cell disease, as well as liver cirrhosis. They may also form in the bile ducts after cholecystectomy (surgical removal of the gallbladder). Progression of Common Bile Duct Stone A blockage in the common bile duct wll lead to obstructive jaundice since there can be no outflow of bile. The complications that ensure are important:
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Acute Cholangitis: There is infection of the stagnant bile which can ascend to the liver. Hepatic abscess : As a result of ascending infection in cholangitis; Pancreatitis: The blockage of the bile duct also affects the pancreas; Secondary Biliary Cirrhosis: With time, in cases of prolonged obstruction there is inflammation, then fibrosis and scarring of the liver, which leads to cirrhosis.

How is Common Bile Duct Stone Diagnosed?

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Full blood count - elevated white cell count signifying infection. Liver function tests - elevated bilirubin, evidence of stasis. Blood cultures - frequently positive in cholangitis. Amylase/Lipase - may be elevated if there is an element of pancreatitis.

How is Common Bile Duct Stone Treated? If the patient has Cholangitis
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Analgesia (narcotics) and IV antibiotics (amoxycillin, metronidazole and gentamicin) are given.

If the obstruction needs to be relieved, this can be done using:

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ERCP (Endoscopic Retrograde Cholangiopancreatography) is performed to cut the sphincter connecting the common bile duct to the duedenum, to allow the stone to pass into the intestine relieving the obstuction. If there is any suspicious pathology this may be biopsied. A cholecystectomy may be indicated at the same time or a later date.

Pathophysiology of gallstone formation Bile is a complex solution of cholesterol, bile-pigments, bile salts, calcium and water. Under certain situations the lining of the gallbladder becomes diseased and the solution becomes unstable leading to crystal formation. Eventually crystals provide a nidus for nucleation and stones form.