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Common duct stone in a patient with cholelithiasis or cholecystitis is usually treated by endoscopic sphincterotomy and stone extraction followed by laparoscopic cholecystectomy For the elderly (> 70 years) or poor-risk patient with cholelithiasis and choledocholithiasis, however, cholecystectomy may be deferred after endoscopic sphincterotomy because the risk of subsequent cholecystitis is low ERCP with sphincterotomy should be performed before cholecystectomy in patients with gallstones and jaundice (serum total bilirubin > 5 mg/dL), a dilated common bile duct (> 7 mm), or stones in the bile duct seen on ultrasound or CT scans (Stones may ultimately recur in up to 12% of patients, particularly in the elderly, when the bile duct diameter is 15 mm, or when brown pigment stones are found at time of the initial sphincterotomy) Endoscopic balloon dilation of the sphincter of Oddi may be associated with a higher rate of pancreatitis than endoscopic sphincterotomy and is generally reserved for patients with coagulopathy, in whom the risk of bleeding is lower with balloon dilation than with sphincterotomy In patients with biliary pancreatitis that resolves rapidly, the stone usually passes into the intestine, and ERCP prior to cholecystectomy is not necessary if an intraoperative cholangiogram is done Choledocholithiasis discovered at laparoscopic cholecystectomy may be managed via laparoscopic common duct exploration or, if necessary, conversion to open surgery or
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Acute obstruction of the bile duct typically produces a transient albeit striking increase in serum aminotransferase levels (> 1000 units/L) Bilirubinuria and elevation of serum bilirubin are present if the common duct remains obstructed; levels commonly fluctuate Serum alkaline phosphatase levels rise more slowly Not uncommonly, serum amylase elevations are present because of secondary pancreatitis When extrahepatic obstruction persists for more than a few weeks, differentiation of obstruction from chronic cholestatic liver disease becomes more difficult Leukocytosis is present in patients with cholangitis Prolongation of the prothrombin time can result from the obstructed flow of bile to the intestine In contrast to hepatocellular dysfunction, hypoprothrombinemia due to obstructive jaundice will respond to 10 mg of parenteral vitamin K or water-soluble oral vitamin K (phytonadione, 5 mg) within 24 36 hours
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Ultrasonography and CT scan may demonstrate dilated bile ducts and radionuclide imaging may show impaired
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Clayton ES et al Meta-analysis of endoscopy and surgery versus surgery alone for common bile duct stones with the gallbladder in situ Br J Surg 2006 Oct;93(10):1185 91 [PMID: 16964628] Drake BB et al Economical and clinical outcomes of alternative treatment strategies in the management of common bile duct stones in the elderly: wait and see or surgery Am J Gastroenterol 2006 Apr;101(4):746 52 [PMID: 16494588] Qureshi W Approach to the patient who has suspected acute bacterial cholangitis Gastroenterol Clin North Am 2006 Jun;35(2):409 23 [PMID: 16880073] Siddiqui AA et al Endoscopic sphincterotomy with or without cholecystectomy for choledocholithiasis in high-risk surgical patients: a decision analysis Aliment Pharmacol Ther 2006 Oct 1;24(7):1059 66 [PMID: 16984500]
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by postoperative endoscopic sphincterotomy Operative findings of choledocholithiasis are palpable stones in the common duct, dilation or thickening of the wall of the common duct, or stones in the gallbladder small enough to pass through the cystic duct Laparoscopic intraoperative cholangiography should be done at the time of cholecystectomy in patients with liver enzyme elevations but a common duct diameter of less than 5 mm; if a ductal stone is found, the duct is explored In the postcholecystectomy patient with choledocholithiasis, endoscopic sphincterotomy with stone extraction is preferable to transabdominal surgery Lithotripsy (endoscopic or external), direct cholangioscopy, or biliary stenting may be a therapeutic consideration for large stones For the patient with a T tube and common duct stone, the stone may be extracted via the T tube Postoperative antibiotics are not administered routinely after biliary tract surgery Cultures of the bile are always taken at operation If biliary tract infection was present preoperatively or is apparent at operation, ampicillin (500 mg every 6 hours intravenously) with gentamicin (15 mg/kg intravenously every 8 hours) and metronidazole (500 mg intravenously every 6 hours) or ciprofloxacin (250 mg intravenously every 12 hours) or a third-generation cephalosporin (eg, cefoperazone, 1 2 g intravenous every 12 hours) is administered postoperatively until the results of sensitivity tests on culture specimens are available A T-tube cholangiogram should be done before the tube is removed, usually about 3 weeks after surgery A small amount of bile frequently leaks from the tube site for a few days Urgent ERCP, sphincterotomy, and stone extraction are generally indicated for choledocholithiasis complicated by ascending cholangitis and are preferred to surgery Before ERCP, liver function should be evaluated thoroughly Prothrombin time should be restored to normal by parenteral administration of vitamin K (see above) Ciprofloxacin, 250 mg intravenously every 12 hours, penetrates well into bile and is effective treatment for cholangitis Alternative regimens in severely ill patients include mezlocillin, 3 g intravenously every 4 hours, plus either metronidazole or gentamicin (or both) The dose of metronidazole is 500 mg intravenously every 6 hours (if there has been no prior manipulation of the duct); the dose of gentamicin is 2 mg/kg intravenously as loading dose, plus 15 mg/kg every 8 hours adjusted for renal function Aminoglycosides should not be given for more than a few days because the risk of aminoglycoside nephrotoxicity is increased in patients with cholestasis Emergent decompression of the bile duct, generally by ERCP, is required for patients who are septic or fail to improve on antibiotics within 12 24 hours Medical therapy alone is most likely to fail in patients with tachycardia, serum albumin < 3 g/dL, marked hyperbilirubinemia, and prothrombin time > 14 seconds on admission If sphincterotomy cannot be performed, decompression by a biliary stent or nasobiliary catheter can be done Once decompression is achieved, antibiotics are generally continued for at least another three days Elective cholecystectomy can be undertaken after resolution of cholangitis, unless the patient remains unfit for surgery
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