Intrahepatic stones Causes

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Intrahepatic stonesCauses

• Migration of gallbladder stones
• Proximal to common bile duct strictures
• Carolis disease
• Recurrent pyogenic cholangitis

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Recurrent pyogenic cholangitisPathology

• Portal bacteraemia ? acute cholangiolitis
• Transmural inflammation ? biliary stricture
• Biliary stasis ? stones formation
• further acute
  cholangitis
• cholangitic liver
  abscesses
• Parenchymal destruction ? liver atrophy
• Cholangiocarcinoma

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Recurrent pyogenic cholangitisIncidence at Queen
Mary Hospital
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40
30
Number of patients
20
10
0
0
10
20
30
40
50
60
70
80
90
100
Age
Age distribution by decades
Represented patients with previous biliary
operations
Fan ST, Surgery, 1991
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Recurrent pyogenic cholangitisPresentation

• Acute cholangitis 60
• Acute pancreatitis
• Jaundice
• Hepatomegaly
• Portal hypertension

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Recurrent pyogenic cholangitisTreatment of acute
cholangitis by conservative treatment

• Failure in 30
• Failure is often due to persistent obstruction in
  the common bile duct

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Recurrent pyogenic cholangitisAcute
cholangitisOrder of preference of biliary
decompression for failure of conservative
treatment
Endoscopic drainage
Radiological drainage
Emergency surgery
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Surgical treatment in acute phaseDecompression
of biliary tract

• Common bile duct exploration, T-tube drainage
• Transhepatic tube drainage for patients with
  intrahepatic stricture and stones

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Transhepatic tube drainage
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Transhepatic tube drainage
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Cholangiogram finding of RPC

• Loss of parallelism of ductal wall
• Excessive branching of intrahepatic ducts
• Arrow-head formation of small ducts
• Strictures
• Stones

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Operations in quiescent phaseCategory of
severity of RPC

• Simple versus complicated cases
• Complicated cases are those with intrahepatic
  duct stricture(s)

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Operation in quiescent phaseSimple cases

• Common duct exploration
• Choledochoscopy
• Choledochojejunostomy
• for dilated and thick wall CBD
• for unimpeded passage of newly formed stones into
  jejunum

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Hepatico / choledocho jejunostomy
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Operations in quiescent phaseComplicated cases

• Hepaticocutaneous jejunostomy
• Stricturoplasty
• Partial hepatectomy

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Hepaticocutaneous jejunostomy

• For repeated or unlimited access to the biliary
  tract by choledochoscopy
• Reopening of stoma for recurrence of stones and
  strictures

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Electrohydraulic lithotripsyIndications

• Large impacted stone
• Stones behind stricture

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Recurrent pyogenic cholangitisPartial
hepatectomy - Indications

• Destroyed liver segment
• Multiple cholangitic liver abscesses
• Concomitant cholangiocarcinoma

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Results of current treatment

• Hepaticocutaneous jejunostomy
• hospital mortality 0
• morbidity 10
• Hepatectomy
• hospital mortality 2
• morbidity 32
• Recurrence of stones
• simple cases 10
• complicated cases 29

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Recurrent Pyogenic Cholangitis
Gallbladder
Intrahepatic Duct Stone
Stricture of Left Hepatic Duct
Common Bile Duct
Stone
Duodenum
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Gallbladder Stone Disease
Cystic- duct
Gallbladder
Common Bile Duct
Stone
Stone
Duodenum