Increased Prevalence of Subclinical Hypothyroidism in Common Bile Duct Stone Patients

Abstract Context: Earlier, we have shown an increased prevalence of previously diagnosed hypothyroidism in common bile duct (CBD) stone patients and a delayed emptying of the biliary tract in hypothyroidism, explained partly by the missing prorelaxing effect of T4 on the sphincter of Oddi contractility. Objective: In this study, the prevalence of previously undiagnosed subclinical hypothyroidism in CBD stone patients was compared with nongallstone controls. Patients: All patients were clinically euthyreotic and without a history of thyroid function abnormalities. CBD stones were diagnosed at endoscopic retrograde cholangiopancreatography (group 1; n = 303) or ruled out by previous medical history, liver function tests, and ultrasonography (control group II; n = 142). Main Outcome Measures: Serum free FT4 and TSH (S-TSH) were analyzed; S-TSH above the normal range (>6.0 mU/liter) was considered as subclinical and S-TSH 5.0–6.0 mU/liter as borderline-subclinical hypothyroidism. Results: A total of 5.3 and 5.0% (total 10.2%; 31 of 303) of the CBD stone patients were diagnosed to have subclinical and borderline-subclinical hypothyroidism, compared with 1.4% (P = 0.05) and 1.4% (total 2.8%, four of 142; P = 0.026) in the control group, respectively. In women older than 60 yr, the prevalence of subclinical hypothyroidism was 11.4% in CBD stone and 1.8% in control patients (P = 0.032) and subclinical plus borderline-subclinical hypothyroidism 23.8% in CBD stone and 1.8% in control patients (P = 0.012). Conclusion: Subclinical hypothyroidism is more common in the CBD stone patients, compared with nongallstone controls, supporting our hypothesis that hypothyroidism might play a role in the forming of CBD stones. At minimum, women older than 60 yr with CBD stones should be screened for borderline or overt subclinical hypothyroidism.

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Prospective evaluation of a selective approach to cholangiography for suspected common bile duct stones

Annals of The Royal College of Surgeons of England ◽

10.1308/003588410x12628812458293 ◽

2010 ◽

Vol 92 (3) ◽

pp. 206-210 ◽

Cited By ~ 48

Author(s):

James Horwood ◽

Fayaz Akbar ◽

Katherine Davis ◽

Richard Morgan

Keyword(s):

Bile Duct ◽

Common Bile Duct ◽

Bile Leak ◽

Bile Duct Stones ◽

Operative Cholangiography ◽

Cbd Stones ◽

Open Operation ◽

Symptomatic Gallstones ◽

History Of ◽

Positive Results

INTRODUCTION Common bile duct (CBD) stones can cause serious morbidity or mortality, and evidence for them should be sought in all patients with symptomatic gallstones undergoing cholecystectomy. Routine intra-operative cholangiography (IOC) involves a large commitment of time and resources, so a policy of selective cholangiography was adopted. This study prospectively evaluated the policy of selective cholangiography for patients suspected of having choledocholithiasis, and aimed to identify the factors most likely to predict the presence of CBD stones positively. PATIENTS AND METHODS Data from 501 consecutive patients undergoing laparoscopic cholecystectomy (LC) for symptomatic gallstones, of whom 166 underwent IOC for suspected CBD stones, were prospectively collected. Suspicion of choledocholithiasis was based upon: (i) deranged liver function tests (past or present); (ii) history of jaundice (past or present) or acute pancreatitis; (iii) a dilated CBD or demonstration of CBD stones on imaging; or (iv) a combination of these factors. Patient demographics, intra-operative findings, complications and clinical outcomes were recorded. RESULTS Sixty-four cholangiograms were positive (39%). All indications for cholangiogram yielded positive results. Current jaundice yielded the highest positive predictive value (PPV; 86%). A dilated CBD on pre-operative imaging gave a PPV of 45% for CBD calculi; a history of pancreatitis produced a 26% PPV for CBD calculi. Patients with the presence of several factors suggestive of CBD stones yielded higher numbers of positive cholangiograms. Of the 64 patients having a laparoscopic common bile duct exploration (LCBDE), four (6%) required endoscopic retrograde cholangiopancreatography (ERCP) for retained stones (94% successful surgical clearance of the common bile duct) and one (2%) for a bile leak. Of the 335 patients undergoing LC alone, three (0.9%) re-presented with a retained stone, requiring intervention. There were 12 (7%) requiring conversion to open operation. CONCLUSIONS A selective policy for intra-operative cholangiography yields acceptably high positive results. Pre-operatively, asymptomatic bile duct stones rarely present following LC; thus, routine imaging of the biliary tree for occult calculi can safely be avoided. Therefore, a rationing approach to the use of intra-operative imaging based on the pre-operative indicators presented in this paper, successfully identifies those patients with bile duct stones requiring exploration. Laparoscopic bile duct exploration, performed by an experienced laparoscopic surgeon, is a safe and effective method of clearing the bile duct of calculi, with minimal complications, avoiding the necessity for an additional intervention and prolonged hospital stay.

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Pre-operative MRCP: is it necessary before routine laparoscopic cholecystectomy to exclude CBD stone-prospective study in tertiary care hospital

International Surgery Journal ◽

10.18203/2349-2902.isj20174636 ◽

2017 ◽

Vol 4 (11) ◽

pp. 3633 ◽

Cited By ~ 1

Author(s):

Ganni Bhaskara Rao ◽

Samir Ranjan Nayak ◽

Sepuri Bala Ravi Teja ◽

Reshma Palacharla

Keyword(s):

Patient Safety ◽

Laparoscopic Cholecystectomy ◽

Bile Duct ◽

Common Bile Duct ◽

Liver Function ◽

Liver Function Test ◽

Ultrasound Examination ◽

Cbd Stones ◽

Function Test ◽

Cbd Stone

Background: Cholelithiasis is a common disease and at present the laparoscopic cholecystectomy is the gold standard treatment. The diagnosis of associated common bile duct stone for patients with gallstones is important for prompt surgical decision, treatment efficacy and patient safety. However, whether upper abdominal ultrasound and Liver function test (LFT) is adequate before doing lap cholecystectomy remains controversial. There are different opinions regarding the routine magnetic resonance cholangiopancreatography (MRCP) to detect the possible presence of common bile duct (CBD) stones before laparoscopic cholecystectomy.Methods: This study was carried on a total of 106 patients who were admitted and treated for gall stone diseases in the Department of General Surgery, GSL General Hospital over a period of 24 months. After admission all cases were subjected for liver function test, USG abdomen and MRCP. The collected observational data was analyzed.Results: Among the 106 patients, a total of 17cases showed concurrent gallstones and choledocholithiasis, 11 cases choledocholithiasis were revealed by ultrasound examination, while 6 cases of choledocholithiasis were not detected by ultrasound examination but were confirmed by MRCP.Conclusions: CBD stone may be missed even in the presence of deranged liver enzymes or dilated CBD in USG abdomen. Hence for patient safety routine preoperative MRCP examination is recommended before doing laparoscopic cholecystectomy to rule out the likelihood of concomitant CBD stones. The cost-effectiveness of such expensive investigation is to be studied further taking into consideration preventive costs and patient morbidity and mortality.

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Laparoscopic Primary Closure of Common Bile Duct Combined with Percutaneous Cholangiographic Drainage for Treating Choledocholithiasis

The American Surgeon ◽

10.1177/000313481007600521 ◽

2010 ◽

Vol 76 (5) ◽

pp. 517-521 ◽

Cited By ~ 2

Author(s):

Shing-Moo Huang ◽

Chung-Chin Yao ◽

Ya-Wen Cheng ◽

Ling-Yun Chen ◽

Huichin Pan ◽

...

Keyword(s):

Bile Duct ◽

Common Bile Duct ◽

Primary Closure ◽

Operation Time ◽

Tube Placement ◽

Control Group ◽

Study Group ◽

T Tube ◽

Cbd Stones ◽

The Common

The aim of this study was to compare the efficacy and safety of laparoscopic primary closure of the common bile duct (CBD) combined with percutaneous transhepatic cholangiographic drainage (PTCD) and laparoscopic choledocholithotomy with T-tube placement for the treatment of CBD stones. Between January 1991 and July 2002, 50 patients with choledocholithiasis and a CBD diameter larger than or equal to 1 cm underwent laparoscopic CBD explorations. The study group consisted of 10 patients undergoing laparoscopic primary closure of the CBD combined with PTCD. The control group consisted of 40 patients undergoing laparoscopic choledocholithotomy with T-tube placement. Parameters were compared statistically. The study group showed higher female/male ratio (6/4 vs 8/32, P = 0.02), less stone numbers (1.90 ± 0.88 vs 3.40 ± 1.65, P = 0.0078), shorter operation time (138 ± 37 minutes vs 191 ± 75 minutes, P = 0.014), and shorter postoperative stays (7 ± 3 days vs 10 ± 3 days, P = 0.0013). It seems that laparoscopic primary closure of the CBD combined with PTCD can shorten the operation time and postoperative stays as compared with laparoscopic choledocholithotomy with T-tube placement for the treatment of CBD stones.

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P-BN39 The perils of MRCP requesting and early associations of data quality and likelihood of a diagnostic result

British Journal of Surgery ◽

10.1093/bjs/znab430.037 ◽

2021 ◽

Vol 108 (Supplement_9) ◽

Author(s):

Callum Jones ◽

Helena Barton ◽

Samir Pathak ◽

Jonathan Rees

Keyword(s):

Bile Duct ◽

Common Bile Duct ◽

Expectant Management ◽

Clinical Information ◽

Common Bile Duct Stones ◽

Magnetic Resonance Cholangiopancreatography ◽

Biliary Tree ◽

Cbd Stones ◽

Optimal Information ◽

Cbd Stone

Abstract Background MRCP (Magnetic resonance cholangiopancreatography) is used most to assess the biliary tree for stones or strictures. Recently, MRCP availability has increased, and it is extensively used to detect of common bile duct (CBD)stones although very frequently no stones are seen. Indeed, the currently recruiting sunflower RCT aims to determine the clinical and cost effectiveness of expectant management versus MRCP in patients undergoing laparoscopic cholecystectomy at low or moderate risk of common bile duct stones. However, it is critical when requesting an investigation that adequate information is provided. This work aimed, to describe the adequacy of information provided and correlate this with the MRCP result. We hypothesised that the less information that was provided the more common a normal result would be. Methods For a three month period (January 2021 to April 2021) all MRCP requests to detect the presence of a CBD stone were reviewed and data obtained from the Radiology CRIS (CDN Radiology Information System, CDN, Sydney, Aus.). The requesting information was compared to three pre-defined criteria (CBD diameter, presence of gallstones and LFT details) that were agreed as the optimal information that a reporting radiologist would require. The number of key pieces of information for each request and whether the request identified a CBD stone were identified. The proportion of MRCPs detecting a CBD stone was calculated according to the number of key pieces of information provided. Results 56 patients were identified, of which 16 (29%) patients had CBD stones. In 24/56 (43%) patients the presence of gallstones on a previous ultrasound was provided, 14/56 (25%) of patients had information about LFTs including bilirubin and a trend in LFTs was not stated for any patient (0/56; 0%). The rate of stone detection was calculated by the number of pieces of information provided. The rate was 71% (5/7) when all 3 pieces of data were provided, 31% (2/13) when two piece of information were provided, 30% (8/27) when a single piece of information was provided, and only 11% (1/11) when none of the specified data were provided. Conclusions It is uncommon for adequate clinical information to be provided in MRCP requests and in 16% of request no key information was provided. The LFT results were frequently omitted and the trend in LFTs never stated. The more key data provided in the request saw a higher proportion of MRCPs where a CBD stone was identified. We recommend that maximal clinical information is mandated for MRCP request perhaps using mandatory fields on electronic requesting systems and that these systems are also used to facilitate recruitment to clinical trials such the Sunflower RCT.

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Direct Peroral Cholangioscopy in the Management of Difficult Biliary Stones: a New Tool to Confirm Common Bile Duct Clearance. Results of a Preliminary Study

Journal of Gastrointestinal and Liver Diseases ◽

10.15403/jgld-162 ◽

2019 ◽

Vol 28 (1) ◽

pp. 89-94

Author(s):

Andrea Anderloni ◽

Francesco Auriemma ◽

Alessandro Fugazza ◽

Edoardo Troncone ◽

Luis Maia ◽

...

Keyword(s):

Bile Duct ◽

Common Bile Duct ◽

Balloon Dilation ◽

Biliary Stones ◽

Serious Adverse Events ◽

Endoscopic Techniques ◽

Cbd Stones ◽

Large Bile Duct ◽

Cbd Stone ◽

Per Oral

Background & Aims: Endoscopic sphincterotomy (ES) with stone extraction is the standard treatment for choledocholithiasis. After stone retrieval, balloon-occluded cholangiography is generally performed to confirm bile duct clearance but can miss residual stones particularly in patients with residual small-sized stones, a large bile duct or pneumobilia. In addition, difficult common bile duct (CBD) stones requiring advanced endoscopic techniques for retrieval are a potential risk factor for choledocholithiasis recurrence.Methods: We performed a retrospective evaluation of a prospectively maintained procedures database. From July 2016 to December 2017, all patients with difficult CBD stones who underwent endoscopic retrograde cholangiopancreatography (ERCP) with papillary balloon dilation-assisted stone retrieval and subsequent direct per-oral cholangioscopy (DPOC) using standard gastroscopes to confirm CBD clearance were analyzed.Results: Thirty-six patients who underwent ERCP and DPOC were included. Technical success, defined as deep intubation of CBD with hepatic hilum visualization, was achieved in 31 of 36 patients (86%). During DPOC, residual CBD stones were visualized and removed in 7 of 31 patients (22.5%). After a mean of 241 ± 56 days of follow-up post-DPOC, no serious adverse events were reported, and there was no evidence orsuspicion of recurrent choledocholithiasis.Conclusions: Direct per-oral cholangioscopy immediately following difficult CBD stone removal was safe, feasible and accurate. In this setting, DPOC at the time of ERCP appears to be a very useful tool to achieve complete clearance of choledocholithiasis.

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EFFICACY OF ERCP WITH SPHINCTEROTOMY OR PAPILLARY BALLOON DILATION IN THE CBD STONES THERAPY

Journal of Medicine and Pharmacy ◽

10.34071/jmp.2014.2.3 ◽

2014 ◽

pp. 19-23

Author(s):

Van Huy Tran ◽

Trung Nam Phan ◽

Khanh Vinh ◽

Minh Tan Le ◽

Yamamoto Kenta ◽

...

Keyword(s):

Bile Duct ◽

Common Bile Duct ◽

Balloon Dilation ◽

Stone Disease ◽

Routine Procedure ◽

Endoscopic Retrograde ◽

Cbd Stones ◽

Biliary Sphincterotomy ◽

Cbd Stone ◽

Ballon Dilation

Background: Common bile duct (CBD) stone is the disease which leads to more severe complications than other cholelithiasis. The last 30 years have seen major developments in the management of CBD stone disease. Endoscopic retrograde cholangiopancreatography (ERCP) has become a widely available and routine procedure. The effect of this therapy is affected by patient’s condition, number, size and site of CBD stone… Aim: To evaluate the results and complications of ERCP in common bile duct (CBD) stones. Patients/Methods: Between 9/2010 and 12/2013, 42 CBD stone patients were included. According to the protocol, we treated, followed up and assessed the success rate, complication rate of ERCP combine with oddi sphincterotomy or papillary ballon dilation. Results: The successful rate of biliary stone removal was 95.2%. The rate of complication was 9.5%. Pancreatitis is common complications (7.1%). Conclusion: ERCP combine with oddi sphincterotomy or papillary ballon dilation is an effective and relatively safe therapy for CBD stones. Keywords: common bile duct stone, ERCP, Biliary sphincterotomy.

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Needle-knife fistulotomy vs. standard biliary sphincterotomy for choledocholithiasis: common bile duct stone recurrence and complication rate

Endoscopy International Open ◽

10.1055/a-1024-3789 ◽

2019 ◽

Vol 07 (12) ◽

pp. E1733-E1741 ◽

Cited By ~ 1

Author(s):

Livia Archibugi ◽

Alberto Mariani ◽

Gabriele Capurso ◽

Mariaemilia Traini ◽

Maria Chiara Petrone ◽

...

Keyword(s):

Bile Duct ◽

Common Bile Duct ◽

Proportional Hazards ◽

Proportional Hazards Model ◽

Cbd Stones ◽

Stone Recurrence ◽

Hazards Model ◽

Kaplan Meier ◽

Biliary Sphincterotomy ◽

Cbd Stone

Abstract Background and study aims With common bile duct (CBD) stones, access to the CBD can be achieved through the papilla orifice followed by standard biliary sphincterotomy (SBS), or through precut fistulotomy (PF) in case of difficult cannulation. The two methods alter papilla anatomy differently, potentially leading to a different rate of stone recurrence. No data have been published on stone recurrence after PF in patients with CBD stones. The aim of this study was to evaluate CBD stone recurrence, reintervention rate after PF versus SBS, and complications. Patients and methods This was a retrospective single-center cohort study including patients undergoing for the first time endoscopic retrograde cholangiopancreatography (ERCP) for CBD stones with PF in case of failed repeated cannulation attempts, matched for sex/age to patients with SBS randomly extracted from our database. T-test and Fisher’s tests were used for continuous and categorical variable comparison. Recurrence probability was calculated with Kaplan–Meier curve. Factors associated with ERCP repetition were evaluated with logistic regression through a Cox’s proportional hazards model. Results Eighty-five patients with PF were included, with 85 matched controls (mean age 68.7 years, 45.9 % males). Overall, patients with PF had the same reintervention rate as those with SBS (14.1 % vs. 12.9 %) with a hazard ratio (HR) of 1.11 (95 % CI 0.49 – 2.50; P = 0.81), but mean time to reintervention was significantly lower (74.9 ± 74.6 vs. 765.6 ± 961.3 days; P < 0.0001), with 100 % of stones recurring within the first year in the PF group vs. 54.5 % in the SBS group (P = 0.01). The only factor associated with ERCP repetition risk was incomplete CBD clearing. Complications, including pancreatitis, did not differ significantly. Conclusions The reintervention rate was significantly higher in the short term after PF. Therefore, closer follow-up in the first 6 to 12 months after ERCP might be appropriate for patients underoing PF.

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The Underlying Mechanisms: How Hypothyroidism Affects the Formation of Common Bile Duct Stones—A Review

HPB Surgery ◽

10.1155/2012/102825 ◽

2012 ◽

Vol 2012 ◽

pp. 1-7 ◽

Cited By ~ 3

Author(s):

Johanna Laukkarinen ◽

Juhani Sand ◽

Isto Nordback

Keyword(s):

Bile Duct ◽

Common Bile Duct ◽

Cholesterol Metabolism ◽

Common Bile Duct Stones ◽

Sphincter Of Oddi ◽

Bile Secretion ◽

Liver Cholesterol ◽

Cbd Stones ◽

Underlying Mechanisms ◽

Hypothyroid Patients

For decades, one well-known risk factor for the development of gallbladder stones has been hypothyroidism. Recent studies have interestingly reported that the risk in particular for common bile duct (CBD) stones increases in clinical and subclinical hypothyroidism. There are multiple factors that may contribute to the formation and/or accumulation of CBD stones in hypothyroid patients, including decreased liver cholesterol metabolism, diminished bile secretion, and reduced sphincter of Oddi relaxation. This paper focuses on the mechanisms possibly underlying the association between hypothyroidism and CBD stones. The authors conclude that when treating patients with CBD stones or microlithiasis, clinicians should be aware of the possible hypothyroid background.

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Endoscopic papillary balloon dilatation may preserve sphincter of Oddi function after common bile duct stone management: evaluation from the viewpoint of endoscopic manometry

Gut ◽

10.1136/gut.41.4.541 ◽

1997 ◽

Vol 41 (4) ◽

pp. 541-544 ◽

Cited By ~ 78

Author(s):

H Sato ◽

T Kodama ◽

J Takaaki ◽

Y Tatsumi ◽

T Maeda ◽

...

Keyword(s):

Bile Duct ◽

Common Bile Duct ◽

Balloon Dilatation ◽

Sphincter Of Oddi ◽

Partial Recovery ◽

Endoscopic Manometry ◽

Basal Pressure ◽

Cbd Stones ◽

Significant Difference ◽

Endoscopic Papillary Balloon Dilatation

Background—Endoscopic papillary balloon dilatation (EPBD) has been reported as a safe and effective alternative to endoscopic sphincterotomy in the management of common bile duct (CBD) stones; its effect on papillary function has yet to be elucidated.Aim—To investigate sphincter of Oddi (SO) motility before and after EPBD to determine its effect on SO function.Patients and methods—The papillary function of 10 patients with CBD stones was studied using endoscopic manometry before and one week after EPBD. The manometric studies were repeated one month after EPBD in seven patients.Results—One week after EPBD, CBD pressure, SO peak pressure, SO basal pressure, and SO frequency decreased significantly. One month after EPBD, however, all parameters increased although the increases in SO basal pressure and CBD pressure were not significant. There was no significant difference in values of any parameter before and one month after EPBD. No serious complications occurred.Conclusion—These data suggest at least partial recovery of papillary function one month after the procedure. EPBD seems to preserve papillary function in treatment of CBD stones; a longer term follow up study with SO manometry should be performed to clarify the effect of EPBD on SO function.

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Laparoscopic Common Bile Duct Exploration as a Rescue Procedure for Failed Endoscopic Retrograde Cholangio-Pancreatography: A Case Report

JOURNAL FOR CLINICAL AND DIAGNOSTIC RESEARCH ◽

10.7860/jcdr/2021/49296.15179 ◽

2021 ◽

Author(s):

Umar Riaz ◽

Abhijit S Joshi

Keyword(s):

Case Report ◽

Bile Duct ◽

Common Bile Duct ◽

Treatment Options ◽

Common Bile Duct Exploration ◽

Endoscopic Retrograde ◽

Therapeutic Modalities ◽

Cbd Stones ◽

Billroth Ii Gastrectomy ◽

Cbd Stone

Across the world, choledocholithiasis is presently treated by a two staged approach of Endoscopic Retrograde Cholangio- Pancreatography (ERCP) followed by Laparoscopic Cholecystectomy (LC); in a vast majority of the situations. Modern day literature abounds with comparative outcomes studies between ERCP and Laparoscopic Common Bile Duct Exploration (LCBDE), as therapeutic modalities for Common Bile Duct (CBD) stones. There are strong arguments both in favour and against both these treatment options, in literature. As per literature, the advantage of LCBDE is that it is a single stage procedure, but requires advanced laparoscopic expertise and a choledochoscope in the setup. The advantage of ERCP is that it is a highly standardised procedure. In expert hands and well equipped setups, it rarely ever fails to deliver. However, ERCP is also a highly operator dependant procedure. Also, in the best of hands, sometimes, local factors such as abnormal anatomy, stone morphology can lead to failures or suboptimal results. As per literature, ERCP to extract CBD stones can fail for various reasons such as failed cannulation, previous Billroth II gastrectomy, large CBD stones, large number of CBD stones etc. The failure in retrieving CBD stones by ERCP is an absolute indication for performing CBDE. Here, authors present a case report of a 73-year-old male with failed ERCP (inspite of two attempts) due to a large, solitary but tightly impacted terminal CBD stone. It hopes to convey the message that in similar situations, LCBDE, tactically using some endoscopy accessories, is a sound backup therapeautic option, inspite of non availability of a choledochoscope in the setup. The novelty of this case was that instead of the standard use of choledochoscope to directly visually confirm the completeness of stone clearance during the LCBDE, intraoperative fluoroscopy has been used effectively for the same; by obtaining good quality proximal and distal occlusion cholangiograms at the end of the procedure.

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