Choledocholithiasis
• Most gallstones; These are stones that cannot pass from the gallbladder to the duodenum and remain in the biliary tract (secondary stones}.
• Stones formed in the bile ducts (primary stones} are brown pigment stones, they form along the long axis of the biliary tract.
• Stones in the biliary tract increase the intraluminal pressure by preventing bile flow and may cause cholangitis.
• Abdominal USG can help in the diagnosis by showing the dilatation of the bile ducts and large stones, if any, in suspected choledochal stones, but it has low sensitivity.
• The definitive diagnosis of common choledochal stones can be made with MRCP, but in patients with a high clinical and laboratory stone probability, ERCP can be performed directly for both diagnosis and treatment purposes. Treatment is removal of stones by sphincterotomy.
• All common choledochal stones, even asymptomatic, must be removed.
• Untreated stones can cause cholangitis, acute pancreatitis and secondary biliary cirrhosis in the long term.
Cholangitis
• Bile stasis in the bile ducts is infected with bacteria. The most common cause is gallstones.
• The causative agent is almost always gram (-) bacteria, most commonly E.coli.
• The most typical findings of a cholangitis attack are right upper quadrant pain, jaundice and fever (Charcot triad).
• There are ALP, GGT, bilirubin increase and leukocytosis in the laboratory. Significant elevation of transaminases may also be observed at the onset of obstruction.
• Biliary pancreatitis can be added to the picture with obstruction of the lower end of the common bile duct and related findings can be seen.
• In cases where cholangitis is suspected, abdominal USG can be useful by showing stones or dilatation of the biliary tract and is preferred as the first imaging method.
• Patients; They are hospitalized, their oral intake is stopped, parenteral fluid is given and broad-spectrum antibiotics are started.
• If biliary obstruction or stone is suspected, the patient should be immediately taken to ERCP.
Standard treatment is endoscopic sphincterotomy, stone extraction and biliary drainage with ERCP.
• Stones that cannot be performed or removed with ERCP are surgically treated with common bile duct exploration.
• Secondary sclerosing cholangitis in the biliary tract due to recurrent cholangitis attacks and, in progressive cases, secondary biliary cirrhosis may be seen.
Cholangiocancer
• It is a primary malignant tumor of the bile ducts that usually occurs with advanced age and is 95% adenocancer.
• Risk factors
primary sclerosing cholangitis
Choledochal cysts, Caroli's disease
Opisthorchis viverrini and Clonorchis sinensis infestations
hepatolithiasis
• The effect of gallbladder and choledochal stones on the development of cancer has not been demonstrated.
• The patient usually comes to the clinic with obstructive jaundice, cholestasis enzymes and direct bilirubin are high.
• Biliary obstruction is best demonstrated by MRCP and ERCP.
• Cholangiocancers are classified as follows according to the place of involvement;
Type 1: Tumor located in the common bile duct below the hilar region.
Type 2 (most common): Tumor located in the hilar region (Klatskin tumor).
Type 3: Tumors involving the common bile ducts above the hilar region (3a=right hepatic duct, 3b=left hepatic duct)
Type 4: Multicentric or both hepatic duct involvement.
• Cases without metastasis are given to surgery, the diagnosis is finalized and the tumor is excised.
• In cases where surgery cannot be performed, palliation is provided by biliary stenting with ERCP.