A typical patient with common bile duct stones will have abdominal pain, chills, high fever and jaundice (Charcot’s triad), and in severe cases, decreased blood pressure and neuropsychiatric symptoms (Reynolds’ pentad); on physical examination, yellow staining of the skin and sclera, right upper abdominal pressure, rebound pain or muscle tension, and sometimes Murphy’s sign (+) may be seen; during the attack there may be no obvious signs and symptoms; a few patients are always asymptomatic. Xu Hongwei, Department of Gastroenterology, Shandong Provincial Hospital.
Laboratory tests: during the attack, there may be an increase in leukocytes and neutrophils; liver function tests may show abnormalities, such as different degrees of increase in bilirubin, alkaline phosphatase, γ-glutamyl transpeptide and serum transaminases; in patients with severe cholangitis, electrolytes and renal function indicators may be abnormal; in the resting phase, the indicators may be normal.
Imaging examination
1, abdominal ultrasonography: It can show the lesions of bile ducts and gallbladder inside and outside the liver, and is an indispensable first-line imaging diagnostic tool before ERCP; however, transabdominal ultrasonography often cannot clearly show the lower part of the common bile duct, and the false-negative rate of diagnosing common bile duct stones is more than 30%, which can easily mistake the gas in the bile duct for stones, and at the same time cannot indicate whether there is stenosis in the lower part of the common bile duct. Therefore, ultrasonography alone is not sufficient to decide whether ERCP treatment should be performed, and further imaging is recommended.
CT: The specificity of diagnosing common bile duct stones is 84-100% and the sensitivity is 65-93%; it can be used as a second-line diagnostic imaging tool for patients with negative ultrasound examinations or for cases requiring further information about the liver, bile, pancreas and surrounding organs.
MRI/MRCP: tomographic MRI examination has similar sensitivity and specificity as CT; MRCP can show biliary and pancreatic duct lesions more visually and clearly, and has a higher diagnostic rate for stones >=3 mm. MRCP has a high reference value for judging the condition and mastering indications and contraindications before ERCP.
4.Ultrasound endoscopy: The sensitivity of diagnosing common bile duct stones is 84-100%, the specificity is 96-100%, and the diagnostic rate is similar to that of ERCP, which has a higher diagnostic accuracy for small stones in the common bile duct and is relatively safe for patients who have not been clearly diagnosed.
ERCP: The sensitivity of diagnosing common bile duct stones is 79-100% and the specificity is 87-100%. There is a certain degree of invasiveness and risk associated with ERCP, patients often need to be hospitalized, the cost is higher, and they also need to bear the risk of operation failure and complications, therefore, in principle, the implementation of purely diagnostic ERCP is not recommended.
5. Diagnosis of common bile duct stones.
In patients with suspicious symptoms/signs, the diagnosis is gradually established through first- and second-line examinations, and then a treatment plan is developed; in cases of suspected bile duct stones, less invasive and highly diagnostic imaging examinations, such as MRCP and ultrasound endoscopy, are recommended, and the implementation of diagnostic ERCP is not recommended; if conditions permit, routine examination of MRCP before ERCP is recommended.
IV. Case selection.
ERCP is not used as a first-line diagnostic tool, and purely diagnostic ERCP should be avoided as much as possible; ERCP should be performed with caution in those who are clinically suspected of having bile duct stones without any imaging evidence; it is recommended that ERCP should only be used for the treatment of already definite cases of common bile duct stones by performing stone removal and biliary drainage.
Patients who have been diagnosed with common bile duct stones, with or without symptoms, should in principle be treated for a limited period of time if there are no special contraindications; ERCP, laparoscopic surgery, and open surgery can be used for treatment, and the most favorable treatment modality for the patient should be selected based on the patient’s condition, the technical conditions of the unit, and the experience of the operator.
Patients with pure extrahepatic bile duct stones, and whose gallbladder has been removed, are generally considered for ERCP bile duct extraction first if there is no special contraindication.
Patients with common bile duct combined with gallbladder stones can be considered for 3 types of treatment: 1) ERCP lithotomy + laparoscopic cholecystectomy; 2) laparoscopic cholecystectomy + common bile duct exploration; 3) open cholecystectomy + bile duct exploration surgery.
Patients with common bile duct stones, if the gallbladder is still in situ and free of stones, and if the gallbladder function is basically normal, they should be managed by preserving the function of the sphincter of Oddi as much as possible.
In acute biliary pancreatitis, if it meets the index of severe disease or is accompanied by cholangitis or obstructive jaundice, emergency ERCP should be performed as early as possible (<72 hours), and EST lithotripsy or bile duct drainage treatment should be implemented, which can reduce complications and mortality; in mild cases, conservative treatment can be given first, and the corresponding endoscopic treatment can be taken at a later stage after the condition is stabilized.
Patients with cirrhosis and portal hypertension are prone to serious complications when performing ERCP and should be performed with caution.
V. Pre-operative preparation for ERCP.
1. Informed consent: Before performing ERCP, the operating physician or primary assistant should explain in detail to the patient and/or family the necessity, possible outcomes, and risks of the ERCP operation, and the patient’s designated delegate should sign a written informed consent. The informed consent should not be too general, but should clearly express the possible complications of ERCP.
2. Coagulation tests: platelet count, prothrombin time or international normalized ratio must be performed before EST, and the test should not be performed more than 72 hours before ERCP; abnormal indicators may increase the risk of bleeding after EST and should be corrected before implementation. Patients on long-term anticoagulation therapy should consider adjusting the relevant drugs before performing EST, such as those taking aspirin and non-steroidal anti-inflammatory drugs should stop for 5-7 days; those taking other anti-platelet coagulation drugs should stop for 7-10 days; those taking warfarin can be switched to low-molecular heparin or normal heparin; and then resume after endoscopic treatment as appropriate.
3, prophylactic antibiotic therapy: routine application of antibiotics before ERCP is not necessary, but those with the following conditions should use antibiotics prophylactically: 1, biliary tract infection and sepsis have occurred; 2, hepatoportal tumor; 3, organ transplantation, immunosuppressed patients; 4, interventional treatment of pancreatic pseudocyst; 5, primary sclerosing cholangitis; 6, those with moderate-high risk cardiac disorders. Broad-spectrum antibiotics are recommended.
4.Sedation and monitoring
5. Preoperative discussion
6. ERCP routine operation.
Insert the duodenoscope through the mouth, through the esophagus, stomach, and into the descending duodenum, straighten the body of the scope, search for the duodenal papilla, and perform biliary cannulation through the duodenal papilla.
1.Papillary sphincterotomy (EST)
2.Papillary balloon dilation
3.Lithotripsy
4.Stenting: In cases of common bile duct stones that are difficult to remove endoscopically, especially in elderly patients who are not suitable for surgery, plastic stents can be left in the bile ducts to help drainage of bile, control infection, reduce frequent attacks, and play a certain role in palliative treatment, and some of the more lax stones may gradually shrink. The long-term stent needs to be replaced in time once the obstruction occurs.
5.Application of nasobiliary drainage tube: temporary drainage measures, mainly applicable to cases with bile duct septic infection, stones not yet clean and needing endoscopic intervention or surgical treatment again, suspected of residual stones or cases with fear of biliary tract infection.
6, the application of pancreatic duct stent: short-term indwelling pancreatic duct stent can help prevent pancreatitis after ERCP or reduce the severity of pancreatitis. For high-risk cases, such as those with difficult intubation, preincisional access to the bile duct, balloon dilated papilla, or SOD patients, prophylactic short-term indwelling pancreatic duct stenting is recommended if conditions allow.
7.Pre-incision: It is an extraordinary means to enter the bile duct when conventional intubation methods are not successful.
8.Mechanical lithotripsy: Larger stones require mechanical lithotripsy mesh basket to crush the stones and then remove them.
VII. Postoperative treatment
The first 24 hours after the operation is the time when complications are most likely to occur, so symptoms and signs should be closely observed. On the day of examination, water and intravenous fluids should be fasted, and diet should be resumed gradually according to the condition. Postoperative laboratory tests for routine blood, blood and urine amylase.
2. Treatment of nasal bile duct The drainage tube should be properly fixed in vitro to prevent dislodgement; the amount and nature of the drained bile should be observed and recorded. If the drainage is left after lithotripsy, it can be removed at an optional stage when it returns to normal after surgery and the imaging confirms that there are no residual stones; if the stones are not yet removed, the second lithotripsy treatment should be arranged. The drainage tube left due to bile duct obstruction is usually a short-term temporary drainage, which can receive surgery at an optional date; if no surgery is planned in the near future, it can be recommended to be replaced with intra-stent drainage if conditions allow.
3, the treatment of biliary stents: according to the condition and the purpose of stent treatment to determine the duration of stent retention, patients are advised to pay attention to the stent in place and patency, once the unexplained fever, jaundice, should be considered stent failure (obstruction or displacement), timely examination, if necessary, replace the stent.
4. Treatment of pancreatic duct stent: The pancreatic duct stent placed to prevent pancreatitis after ERCP should not be left in place for too long, and it is recommended to be removed within 2 weeks after operation.