Choledocholithiasis

thumb|250px|ERCP – kámen ve žlučovodu Choledocholithiasis is the presence of bile stones in the extrahepatic or intrahepatic bile ducts.

The stones are deposited in the bile duct, where they grow and can thus dilate the bile ducts. Choledocholithiasis complicates cholelithiasis in 8–15%.

Bile duct stones are divided into


 * 1) primary – arise in the bile ducts, usually in places of congenital, inflammatory or traumatic stenoses or dilatations;
 * 2) secondary – stones enter the bile ducts from the gallbladder, where they also formed.

The clinical picture
Choledocholithiasis is manifested in most cases by abdominal pain, which is located either in the right upper portion or more often in the epigastrium. The pain lasts for several hours and it can return after a few days to months. The disease may also manifest as symptoms of gallbladder obstruction or in the form of biliary pancreatitis or acute cholangitis. Jaundice is variable in choledocholithiasis and depends on the degree of bile duct obstruction. In 10–20% of cases, the disease is asymptomatic.

Diagnostics and laboratory tests
Laboratory tests reflect the degree of obstruction and inflammation of the bile ducts. In patients we measure sedimentation, CRP , blood count and during the feverish period we take blood culture. During obstruction, we encounter increased parameters of cholestasis (direct bilirubin, ALP , GMT). Choledocholithiasis is confirmed by cholangiography - it is most often used endoscopically (ERCP), less often percutaneously (PTC). Biliary dilatation can be seen on USG, but stones are misdiagnosed. In case of unclear diagnosis, we choose magnetic resonance imaging - cholangiopancreatography (MRCP).

We diagnose choledocholithiasis in:

- patients after cholecystectomy who again have pre-operative symptoms or develop intermittent jaundice and fever;

- patients with congenital, tumorous or post-inflammatory stenoses of the bile ducts.

Therapy

 * without therapy – minor attacks with fever and mild jaundice
 * antibiotic treatment – in the elderly and immunosuppressed
 * endoscopic and transhepatic procedures – - papillotomy, mechanical lithotripsy, extraction of stones, implantation of endoprostheses into the bile ducts (temporary solution), laser or electrohydrolytic destruction of stones
 * surgical procedures – in case of endoscopy failure or in severe septic condition
 * extracorporeal shock wave lithotripsy – for large stones that cannot be removed endoscopically

Reference Articles
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 * Bile ducts
 * Cholelithiasis
 * Inflammatory diseases of the gallbladder and bile ducts
 * Diseases of the gallbladder and pancreas in children
 * Endoscopic retrograde cholangiopancreatography