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Intrahepatic stones Causes

Intrahepatic stones Causes. Migration of gallbladder stones Proximal to common bile duct strictures Caroli’s disease Recurrent pyogenic cholangitis. Recurrent pyogenic cholangitis Pathology. Portal bacteraemia  acute cholangiolitis Transmural inflammation  biliary stricture

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Intrahepatic stones Causes

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  1. Intrahepatic stonesCauses • Migration of gallbladder stones • Proximal to common bile duct strictures • Caroli’s disease • Recurrent pyogenic cholangitis

  2. 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

  3. Recurrent pyogenic cholangitisIncidence at Queen Mary Hospital

  4. 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

  5. Recurrent pyogenic cholangitisPresentation • Acute cholangitis 60% • Acute pancreatitis • Jaundice • Hepatomegaly • Portal hypertension

  6. Recurrent pyogenic cholangitisTreatment of acute cholangitis by conservative treatment • Failure in 30% • Failure is often due to persistent obstruction in the common bile duct

  7. Recurrent pyogenic cholangitisAcute cholangitisOrder of preference of biliary decompression for failure of conservative treatment Endoscopic drainage Radiological drainage Emergency surgery

  8. 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

  9. Transhepatic tube drainage

  10. Transhepatic tube drainage

  11. Cholangiogram finding of RPC • Loss of parallelism of ductal wall • Excessive branching of intrahepatic ducts • Arrow-head formation of small ducts • Strictures • Stones

  12. Operations in quiescent phaseCategory of severity of RPC • Simple versus complicated cases • Complicated cases are those with intrahepatic duct stricture(s)

  13. 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

  14. Hepatico / choledocho jejunostomy

  15. Operations in quiescent phaseComplicated cases • Hepaticocutaneous jejunostomy • Stricturoplasty • Partial hepatectomy

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

  17. Electrohydraulic lithotripsyIndications • Large impacted stone • Stones behind stricture

  18. Recurrent pyogenic cholangitisPartial hepatectomy - Indications • Destroyed liver segment • Multiple cholangitic liver abscesses • Concomitant cholangiocarcinoma

  19. 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%

  20. Recurrent Pyogenic Cholangitis Gallbladder Intrahepatic Duct Stone Stricture of Left Hepatic Duct Common Bile Duct Stone Duodenum

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