BILE DUCT CALCULI: CLINICO-PATHOLOGICAL EVALUATION …



RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DESSSERTATION

1. Name of the candidate and address: DR. SUNIL KUMAR SHETTY S

Sulakshana, #156/2AB, 2nd cross,

Muneshwara Block, Hulimavu,

Bannerghatta Road, Bangalore

560076

2. Name of the institution: KEMPEGOWDA INSTITUTE OF

MEDICAL SCIENCES AND RESEARCH CENTRE.

3. Course of study and subject: M.S. (GENERAL SURGERY)

4. Date of admission to course: June 1st 2009

5. Title of the topic: Clinical Evaluation and Management

of Choledocholithiasis

6. BRIEF RESUME OF THE INTENDED WORK:

6.1 Need for the study:

a. Stones in the Common Bile Duct (CBD) and gall bladder are one of the commonest pathology encountered by the surgeons and are almost always associated with stones in the gall bladder [22].

b. Approximately 10% of patients with gall stones have CBD stones [23].

c. Choledocholithiasis causes more morbidity and mortality than cholelithiasis.

d. The anatomical location of the stone makes its extraction a difficult process.

e. Complications of Choledocholithiasis can range from trivial elevation in the liver function tests to frank obstructive jaundice and pancreatitis.

f. Surgery remains the mainstay of therapy for stones in the bile duct.

g. Newer techniques like ERCP have made the treatment of bile duct stones easier if detected at an earlier stage.

6.2 Review of literature:

A. The history of gallstones in probably as old as the evolution of humans.

1. The first documented descriptions are likely those that tell of gallstones in Egyptian mummies dating back nearly 2000 years before Christ [1].

2. In 1556, Realdo Colombo, an anatomist from Padua, Italy, performed an autopsy on the founder of the Jesuit Order, Saint Ignatius of Loyola, who died of what was probably complications of gallbladder disease; numerous stones were found in the gallbladder and a large one in the distal common duct, which had eroded into the portal vein. This situation led the famous English anatomist Francois Glisson to state in 1678 “that only death was the solution for a biliary colic” [2].

3. On May 6, 1840 the hero of the Independence of Colombia, General Francisco de Paula Santander, one of the leading collaborators of the Liberator Simon Bolivar, died in Bogota of what was undoubtedly a case of acute cholangitis [3, 4]. At autopsy a 2.3 cm calculus was found impacted in the distal CBD.

4. After the first cholecystectomy in 1882, there were several attempts to operate on the CBD, all of which resulted in the death of the patient.

5. The first successful CBD exploration was done by Thornton [5] on May 9, 1889, followed shortly by the work of Ludwig Courvoisier and Hans Kehr, who introduced use of the T-tube for drainage and decompressing the biliary tree after exploration of the CBD, which made the operation much safer [7].

6. Toward the end of the nineteenth century, one of the most famous American surgeons,William Halsted, operated on his mother, who died later of complications of choledocholithiasis. He succumbed himself in 1922 of the same problem after three unsuccessful operations performed on him by his disciples at Johns Hopkins. At autopsy, a large stone was found impacted at the ampulla of Vater [8]. For several decades there was little progress in the diagnosis of CBD stones until the introduction of operative cholangiography by Pablo Mirizzi of

Cordoba. [9].

7. Over the next few decades several important discoveries in the diagnosis and treatment of CBD calculi took place among which are the use of balloon catheters by Fogarty et al. [10], percutaneous extraction of CBD calculi through the T-tube by Mazzariello and Burherne [11], and introduction of endoscopic retrograde cholangiopancreatography (ERCP) [12–14].

8. During the last decade the revolutionary use of minimally invasive

surgery [15, 16] with exploration of the CBD during laparoscopic cholecystectomy [17, 18], and lately the advent of magnetic resonance imaging cholangiography [19, 20] (MRIC) to diagnose the presence of CBD stones have greatly changed the management strategies of bile duct stones.

9. With the advent of laparoscopic cholecystectomy, profound changes occurred in the practice of biliary tract surgery. Many patients now come to surgery at an earlier stage of the disease, before complications arise; and as a consequence, the number of explorations of the bile ducts has decreased significantly [21].

B. Almost in all the cases stones initially form in the gall bladder and then they migrate into the common bile duct, which is why they are called secondary stones. CBD stones either pass into the duodenum or may stay in the bile duct gradually increasing in size, and resulting in biliary stasis and obstruction. This may lead to the formation of additional primary bile duct stones. Primary stones may also form in the rare instance of gall bladder agenesis [24].

C. Stones can also develop after infestation of the biliary tree with worms like ascaris lumbricoides or clonorchis sinensis, cholangitis, strictures and cystic dilatations. [22, 25]

D. Stones in the bile duct are more often associated with infected bile (80%) than are the stones in the gall bladder. [22]

E. The frequency of bile duct stones increases with advancing age. For patients less than 60 years of age, the frequency of secondary stones ranges between 4-7%. This increases to 18% in patients between 70-79 years and more than 30% in those above 80 years of age. [26]

F. The clinical picture ranges from asymptomatic patients to severe bouts of pain in the right hypochondrium, jaundice and fever with rigors (Charcoat’s triad), patients are often ill and feel unwell [22, 26]. In patients having asymptomatic gall bladder stones, the risk of developing symptomatic bile duct stones is low ( ................
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