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49 year old female with epigastric pain

49 year old female with epigastric pain. Juanita Halls MD April 27, 2005. Case. 49 year old female with history of Hodgkin’s lymphoma, breast cancer and valvular heart disease with CHF presents with epigastric pain S/p splenectomy and XRT 1977 S/p cholecystectomy 1990

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49 year old female with epigastric pain

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  1. 49 year old female with epigastric pain Juanita Halls MD April 27, 2005

  2. Case 49 year old female with history of Hodgkin’s lymphoma, breast cancer and valvular heart disease with CHF presents with epigastric pain S/p splenectomy and XRT 1977 S/p cholecystectomy 1990 S/p Mastectomy, XRT and chemo 1998 S/p pacemaker 2002 Meds: Furosamide Losartan Spironolactone ASA Tamoxifen

  3. 4/28: PE visit ROS: “stomach pain”, intermittent, worse after eating, better lying down, in past responded to ranitidine. Treated with ranitidine 150 bid 5/7: took ranitidine 3 days- side effects so stopped, epigastric pain better 6/7: pain recurred treated with Prilosec Called 2 weeks later and pain resolved

  4. 7/2: Epigastric pain worse, some nausea Prilosec increased to bid 8/27: Had quit all caffeine, off Prilosec and no pain 9/14: 24 hours of epigastric pain after onion rings, cheese burger and a beer on 9/5 now intermittent pain occ radiates to back no nausea/vomiting/ diarrhea

  5. VS: 137# BP 102/65 HR 65 RR 12 Afebrile Abd: Normal BS. Surgical scars. Soft. Mild tender LUQ. No rebound or guarding. No hepatomegaly or masses

  6. Labs: DateBiliAlk phosALTAST 8/4 0.2 91 *139 *59 8/26 73 49 36

  7. What is your differential diagnosis? What additional tests would you order?

  8. Differential diagnosis GERD Gastritis PUD Pancreatitis Hepatitis Partial SBO Recurrent lymphoma Recurrent breast cancer

  9. Labs: DateBiliAlk phosGGTALTAST 9/14 128 *379 *263 *171 9/27 0.2 *144 57 37 9/14 amylase = 54 lipase = 196 9/27 Hepatitis A, B and C = negative 9/24 Abdominal CT = negative Upper endoscopy pending

  10. What is your differential now? What would you do next? A diagnostic test was ordered.

  11. ERCP requested - done October 4 CBD - medium sized filling defects Sphincterotomy performed: several soft yellow stones and stone material removed Cholangiogram: no residual filling defects

  12. Objectives Common bile duct stones: • Detection • Incidence • Etiology • Risks • Treatment

  13. CBD Stones • Concomitant gallbladder and CBD stones • Post cholecystectomy CBD stones • Retained • Recurrent

  14. Suspect CBD stones • Classic obstructive symptoms • fever, RUQ pain, jaundice • Recurrent symptoms after cholecystectomy • Pancreatitis

  15. Suspect CBD stones • Hepatic biochemical tests • increased bili (> 2mg) • alk phosphatase (>150) • transaminases (2X normal) • RUQ ultrasound or CT scan • dilated CBD

  16. Detection of CBD stones • RUQ ultrasound (sens 18-74%) • CT scan (sensi 76-90%) • IV cholangiography • Intraoperative cholangiography • Intraoperative CBD exploration

  17. Detection of CBD stones • ERCP(Endoscopic retrograde cholangiography) • Gold standard for detection and exclusion of CBD stones • Diagnostic and therapeutic • Failure to cannulate about 5 % • Serious Risks about 5 %: • Pancreatitis, perforation, cholangitis, bleeding, sepsis, death

  18. ERCP • Single small bile duct stone with sphincterotome in position. • (B) Clear bile duct after sphincterotomy and stone extraction.

  19. Detection of CBD stones • MRCP (Magnetic resonance cholangiopancreatography) • Non-invasive • Detect stones as small as 2 mm • Sens 90-100% and spec 92-100% are close to ERCP • Useful to exclude CBD stones and avoid ERCP or an intraoperative evaluation of CBD Gastrointest Endosc 56(6 suppl); S178-82, 2002

  20. MRCP Patient with abdominal pain and elevated alkaline phosphatase. ARROW = 1.4 cm, well-defined, low-signal intensity stone in the dilated distal common bile duct. ARROWHEAD = The normal-caliber pancreatic duct.

  21. Study (Surg Lap Endosc 8:349, 1998 ) 316 patients having laparoscopic cholecystectomy 63 patients had increased bili, alk phos or GGT or dilated CBD on US and had ERCP 12 (3.8 %) had CBD stone

  22. Study (continued) 3 year f/u of 253 patients: 6 (2.3%) had retained CBD stone 4/4 with symptoms – jaundice/biliary colic/abn labs 2/4 with abn labs but asx

  23. Incidence of CBD stones At time of cholecystectomy: 2.5 – 10 % (mean 6 %) Undetected retained CBD stones: 1-3 % over 3 years Recurrence of CBD stones: 24% over 15-17 years Surg Lap Endosc 8:349, 1998 Gastrointest Endosc 44:643, 1996

  24. Why do CBD stones form? • Passed into CBD from gallbladder • Form in the CBD: • Bacteria in biliary tree and stasis promote stone formation • ERCP may increase bacterial contamination but should decrease stasis

  25. Risks of Common Bile Duct stones (choledocholithiasis) • Increased risk of: • cholangitis • pancreatitis • biliary obstruction

  26. Treatment of CBD stones Endoscopic sphincterotomy (ES) If concomitant gallstones: Laparoscopic cholecystectomy 48 hours later

  27. Endoscopic sphincterotomy • Procedure: • Cannulate CBD with sphincterotome • Cut Sphincter of Oddi • Remove stones with basket or balloon • If extraction fails use lithotripsy: mechanical, extracorporeal shock wave, laser, electrohydraulic, chemical

  28. Spincterotomy

  29. ERCP and ES • Stone impacted in mid bile duct. • Mechanical lithotripsy after sphincterotomy. • Completion cholangiogram after stone extraction

  30. ES Basket extraction of multiple bile duct stones after endoscopic sphincterotomy.

  31. Spincterotomy

  32. Spincterotomy

  33. Spincterotomy

  34. Spincterotomy

  35. Gallstone being removed

  36. Gallstones being removed

  37. Gallstones being removed

  38. Endoscopic sphincterotomy • Complication rate 5 – 10 % • Pancreatitis • Bleeding • Cholangitis • Retroperitoneal perforation • Mortality 0 - 0.4 % • NEJM 1996;335:909 (2400 patients – 17 sites) • Ann Surg 1998;201-4 (1900 patients – 7 sites)

  39. Summary • CBD stones are fairly common • Suspect if symptoms of biliary obstruction and/or abnormal Bili/transaminases and/or abnormal US • Diagnose with MRCP or ERCP • Treat with endoscopic sphincterotomy

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