intrahepatic bile duct stones



Overview

What are intrahepatic bile duct stones?

Definition

Intrahepatic bile duct stones are bile duct stones that originate above the bifurcation of the right and left hepatic ducts.

The stones may be widely distributed throughout the intrahepatic bile duct system, or they may be scattered in a branch of the intrahepatic bile ducts, or they may occur in the bile ducts of a lobe or segment of the liver.

It is more common for stones to occur in the left intrahepatic bile duct.

Classification and staging

Classification of gallstones according to their composition

Bile pigment stones: The main component is bilirubin, which is black in color.

Cholesterol stones: composed mainly of cholesterol, often yellowish-green in color.

Mixed stones.

Classification according to the extent, degree of lesion and combination of extrahepatic conditions

According to the distribution range of stones in the liver, the corresponding degree of lesions in the hepatic ducts and liver, and whether combined with extrahepatic bile duct stones, they can be divided into three types.

Type I (regional type): the stones are limitedly distributed along the intrahepatic biliary tree within 1 or several liver segments.

Type II (diffuse type): stones are spread throughout the bile ducts of both liver lobes. Depending on the hepatic parenchymal lesions, it includes 3 subtypes, IIa, IIb, and IIc.

Type E (additional type): refers to the combination of extrahepatic bile duct stones. It can be divided into 3 subtypes according to the status of Oddi’s sphincter.

Morbidity

Intrahepatic bile duct stones are relatively common in Asia, with a prevalence of 2% to 25% in China, Korea, and Japan.

They are relatively rare in Western countries, with a prevalence of 0.6% to 1.3%.

The prevalence of intrahepatic bile duct stones in China has decreased significantly, but the number of patients is still high. The prevalence varies from region to region, and the degree of decline also varies.

Questions you may be concerned about

Can intrahepatic bile duct stones heal on their own?

Intrahepatic bile duct stones do not heal on their own.

Intrahepatic bile duct stones are a common and difficult-to-treat bile duct disease in China, which is mainly related to bile duct infections, bile duct parasites, bile duct anatomical variations and malnutrition.

In acute attack, there may be swelling and pain in the liver area and fever, and corresponding symptoms and signs appear in the complication of bile duct septic infection and liver abscess, etc. In the late stage, biliary cirrhosis appears, and bile duct cancer may also be induced, and it can not be cured by itself mainly by surgical treatment.

How to treat intrahepatic bile duct stones?

Asymptomatic stones can be left untreated with regular observation and follow-up.

Those with recurring clinical symptoms can be treated with surgery.

In the initial stage, the main treatment is incision and stone removal or choledochoscopy (including percutaneous choledochoscopy); while liver lesions with fibrosis and atrophy require lobectomy; when it develops to severe biliary cirrhosis and portal hypertension, liver transplantation may be the only option.

What medication can I take to get rid of intrahepatic bile duct stones?

Intrahepatic bile duct stones cannot be expelled with medication, which can only relieve symptoms.

The main treatment for this disease is surgery, including choledochotomy, hepatic lobectomy, bile-intestinal anastomosis, liver transplantation, etc. The principle of treatment is to remove as many stones as possible.

The principle of treatment is to remove the stones as much as possible, relieve the bile duct stenosis and obstruction, remove the stone site and infected lesions, restore and establish smooth bile drainage, and prevent the recurrence of stones.

Causes

Causes

The causes of intrahepatic bile duct stones are complex and can be related to the following factors.

Biliary tract infections.

Biliary parasites such as Ascaris lumbricoides and Treponema pallidum.

Biliary stagnation.

Anatomical variations of the bile ducts.

Malnutrition.

Genetic factors: The disease is now considered to be polygenic. Those with a family history of cholelithiasis are at increased risk of developing the disease.

High risk factors

High-fat, high-protein, high-calorie, low-fiber diet.

Women older than 40 years of age.

Obesity.

Multiple births.

Family history of cholelithiasis.

Pathogenesis

The basic pathogenesis of bile duct stones: bile sludge from various causes, inflammation, infection, biliary ascariasis and other factors lead to changes in the nature of the bile, bile components are oversaturated, leading to precipitation of bile components and easier precipitation of crystals, which in turn produces stones.

When an infection occurs in the bile duct, bacteria secrete enzymes that promote calcium bilirubinate oversaturation, which then combines with other substances in the bile to form stones.

Symptoms

Symptoms of intrahepatic bile duct stones are often atypical. Smaller stones that are scattered throughout the bile ducts of the liver usually do not cause symptoms.

The main symptoms are

Epigastric pain: usually only persistent swelling or dull pain in the right upper abdomen and back of the chest, but in a small number of cases, typical biliary colic (i.e., intolerable pain) may occur, and biliary colic occurs mostly after meals or at night.

Jaundice: When the bile ducts of both sides or the left and right lobes are obstructed by stones, jaundice may occur, which is manifested by yellowing of the white eyeballs (sclera) and skin, and deepening of the color of the urine.

Epigastric tenderness: an enlarged liver with tenderness is often palpable on physical examination.

Belching, anorexia of grease.

Epigastric mass, etc.

Other symptoms

When jaundice is complicated by biliary tract infection, chills and high fever may occur.

Nausea, vomiting.

Loss of appetite and weight loss.

If accompanied by cirrhosis, there may be blood in the vomit and stool.

A few may have percussion pain in the right upper abdomen.

Complications

Acute purulent cholangitis

The main manifestations are right upper abdominal pain, chills, high fever and jaundice.

Ultrasound may reveal dilatation of intra- and extrahepatic bile ducts or bile duct stones.

Laboratory tests may show leukocytosis and other manifestations.

Biliary liver abscess

There may be right upper abdominal pain or no abdominal pain.

It presents with chills, high fever, may have jaundice, and tends to have a long course.

Biliary hemorrhage

In the case of small amount of bleeding, it only shows black stool or positive fecal occult blood test.

The typical clinical manifestations of massive biliary bleeding are the triad: biliary colic, jaundice, and upper gastrointestinal bleeding (blood in vomit, blood in stool).

Biliary liver abscess

A late complication of intrahepatic bile duct stones.

There may or may not be right upper abdominal pain, manifested by chills and high fever, jaundice may or may not be present, and the course of the disease is usually long.

Bile duct cancer

In the complication of bile duct cancer, it can be manifested as frequent and aggravated episodes of epigastric pain, which is limited to a certain part, obvious pressure pain in the right upper abdomen or subxiphoid process, and palpable mass with pressure pain.

Liver failure

Manifestation of weakness, high degree of fatigue, weight loss, and in severe cases, difficulty in getting up and moving around, or even inability to take care of oneself.

Severe gastrointestinal symptoms: extreme loss of appetite, anorexia, stuffy and uncomfortable epigastrium, nausea, vomiting and eructation may be present. Abdominal distension is obvious, and bowel sounds (the gurgling sound made by gas and liquid in the intestines with intestinal peristalsis) are weakened or lost.

Progressive worsening of jaundice: Hepatocellular jaundice is predominant, mostly characterized by progressive deepening of scleral and skin yellowing.

Obvious bleeding tendency: skin purpura or petechiae, spontaneous gum bleeding, nosebleed, upper gastrointestinal bleeding may occur.

Fever: some patients may have persistent low-grade fever. Severe cases may be complicated by cerebral edema and hepatic encephalopathy, ascites, hepatorenal syndrome, upper gastrointestinal hemorrhage, and severe secondary infections.

Consultation

Department of Medicine

General Surgery

Consult the doctor promptly if symptoms such as upper abdominal pain or discomfort, loss of appetite, jaundice, nausea, vomiting, chills, fever, etc. appear.

Gastroenterology

You can also consult the Department of Gastroenterology for the above symptoms.

Emergency Medicine

Go to the Emergency Department immediately if you experience symptoms such as abdominal cramps, persistent pain, fever, or severe vomiting.

Preparation for medical treatment

Preparing for your visit to the doctor: registration, preparation of documents, and frequently asked questions

Tips for seeking medical treatment

Try to keep a record of your symptoms and their duration before going to the emergency room.

Do not take painkillers by mouth before the visit, as this may affect the doctor’s judgment of your condition.

Preparation Checklist

Symptom list

Pay particular attention to the time of onset of symptoms, special manifestations, etc.

What is the discomfort? How long has it lasted?

What is the pain?

Is the abdominal pain related to breathing, position?

Is there a fever?

Any yellowing of the sclera or skin?

Do you eat regularly? Do you eat breakfast every day?

Prefer greasy or light food?

List of medical history

Any history of gallbladder or bile duct stones?

Have you had any examination or treatment? What are the results?

Checklist

Test results in the last six months, which can be brought to the doctor’s office

Blood test, liver function

Abdominal ultrasound, CT, magnetic resonance cholangiopancreatography (MRCP)

Diagnosis

Diagnostic basis

Medical history

History of biliary tract infections and biliary parasites.

Family history of cholelithiasis.

Clinical manifestations

Symptoms: epigastric pain or discomfort, loss of appetite, jaundice, nausea, vomiting, chills and fever may be present.

Signs: there may be pressure and percussion pain in the hepatic region, and some of them may touch the enlarged gallbladder or liver.

Laboratory tests

Blood biochemistry: it can know whether there is abnormal liver function or not, and those with impaired liver function may have elevated serum bilirubin, aminotransferase, alkaline phosphatase and so on.

Urine examination: urine bilirubin can be elevated, urinary bilirubin decreased or disappeared.

Fecal examination: decreased fecal bile.

Imaging

Ultrasound

Ultrasound is the preferred examination method.

It can detect stones, define the size and location of stones, and find out whether there is any combination of bile duct obstruction.

Dilatation of the bile ducts and images of stones in the common hepatic duct or bile ducts can be seen.

CT examination

It can show the distribution of intrahepatic stones and the dilatation of bile ducts, and has important diagnostic value for intrahepatic bile duct stones.

It is mostly used to determine patients with hepatobiliary ducts and cirrhosis combined with cancer.

Magnetic resonance cholangiopancreatography (MRCP)

It is more comprehensive and three-dimensional for the distribution of intrahepatic stones, stenosis and dilatation of the bile duct system.

Differential Diagnosis

Gallbladder stones

Similarities: Asymptomatic or only epigastric discomfort, fullness after meals, aversion to greasy food.

Differences: gallbladder stones without acute inflammation will resolve on their own after a few minutes or hours, and can be differentiated by ultrasound examination.

Extrahepatic bile duct stones

Similarity: intermittent paroxysmal pain or colic under the raphe, often accompanied by jaundice, fever and chills.

Difference: extrahepatic bile duct stones and intrahepatic bile duct stones occur in obviously different places, ultrasound, CT, MRCP can be distinguished.

Jaundice hepatitis

Similarity: both have jaundice.

Difference: Jaundice hepatitis has obvious symptoms of hepatitis such as fatigue, anorexia, nausea, etc., and can be distinguished by ultrasound.

Others

In the presence of biliary colic and jaundice, intrahepatic bile duct stones need to be differentiated from other diseases as follows.

Differentiation of biliary colic

When biliary colic occurs in intrahepatic bile duct stones, it should be differentiated from biliary ascariasis, acute pancreatitis, perforated peptic ulcer, acute intestinal obstruction, acute intestinal torsion, intestinal perforation, acute appendicitis with perforation, mesenteric vascular embolism or thrombosis, ectopic pregnancy in females, and torsion of the tip of ovarian cysts.

Differentiation of jaundice

When biliary colic occurs in intrahepatic bile duct stones, it needs to be differentiated from acute viral hepatitis, pancreatic head cancer, cholangiocarcinoma, primary liver cancer metastasized to lymph nodes in the hilar region (enlarged lymph nodes may compress the common bile duct and lead to jaundice), and so on.

Treatment

Aims and principles of treatment

Purpose of treatment

Relieve symptoms, reduce recurrence, eliminate stones and avoid complications.

Principles of treatment

Asymptomatic ones can be left untreated, but should be followed up regularly.

Acute exacerbation should be preceded by non-surgical treatment, and after symptoms are controlled, further examination should be conducted to clarify the diagnosis.

If the condition is serious and non-surgical treatment is ineffective, timely surgical treatment should be carried out on the basis of preliminary diagnosis.

Non-surgical treatment

Suitable people

Young patients who are having their first attack.

Those whose symptoms are rapidly relieved by non-surgical treatment.

Those with atypical clinical symptoms.

Those who have had an attack for more than 3 days, with no indication for emergency surgery, and whose symptoms have subsided under non-surgical treatment.

Treatment method

General treatment

Bed rest, dietary abstinence or low-fat diet, fluid infusion, correction of water and electrolyte disorders and acid-base balance imbalance, anti-infection, antispasmodic and analgesic, choleretic and supportive symptomatic treatment.

There is shock should be strengthened anti-shock treatment, such as oxygen, maintain blood volume, timely use of blood pressure medication.

After the above treatment, most of them can be relieved, and after 4 to 6 weeks after passing the acute phase, definitive biliary surgery can be performed again, which can save the patient from the pain of re-operation.

Percutaneous Transhepatic Caval Drainage (PTCD)

Refresh

For severe bile duct obstruction or septic cholangitis, PTCD is performed to drain the bile ducts, reduce biliary pressure, control infection, reduce morbidity and mortality, and gain surgical time.

A fine needle is used to puncture the target bile duct where the stone is located through the skin for drainage.

Endoscopic sphincterotomy (EST)

With the rapid development of therapeutic endoscopy in recent years, endoscopic duodenal papillotomy for stone extraction (with balloon or mesh basket), lithotripsy mesh basket lithotripsy, and transoral choledochoscopy with direct visualization of laser, liquid electrode, and high-frequency electric current lithotripsy have achieved good results in the treatment of bile duct stones.

It provides a new treatment measure for people who should not have surgery or cannot tolerate surgery.

Young patients are advised to choose this method carefully.

Surgical treatment

Preoperatively, it is necessary to correct the imbalance of water, electrolyte acid-base balance, use effective antibiotics to control infection, and strengthen the protection of liver function; postoperatively, attention should be paid to the systemic nutrition and the balance of water, electrolyte, acid-base, and the rational use of antibiotics, and the prevention and treatment of various complications.

Choledochotomy

The basic method of treating bile duct stones.

The purpose is to explore the situation of bile duct patency, take out the stones therein, flush the bile duct, T-tube drainage, and eliminate bile duct infection.

To prevent missing lesions, intraoperative cholangiography or choledochoscopy is necessary.

Choledocho-jejunostomy

Choledochoduodenal anastomosis

There are side-to-side anastomosis and end-to-side anastomosis.

Allows bile to flow into the intestine via a short circuit.

It is prone to upstream infection and is no longer used.

Sphincter of Oddi incision plasty

The procedure is essentially a low choledochoduodenal anastomosis.

It is more complicated, has certain complications, and is basically no longer used clinically.

Biliary jejunal Roux-en-Y anastomosis or modified collateralized anastomosis without dissecting the jejunum

This procedure is commonly used in the treatment of bile duct stones and cholangitis.

It reduces the chance of upstream infection and is also effective in avoiding restenosis.

It is superior to choledochoduodenal anastomosis anastomosis in terms of long-term results and complication rates.

Hepatic lobectomy

Indications: It is suitable for those who have many intrahepatic bile duct stones, which are confined to one side of the liver lobe (segment), and can not be removed by other surgeries, or those who have atrophy of liver tissue.

The diseased liver lobe (segment) can be removed and the lesion can be eradicated.

Liver transplantation

Indications: The whole liver bile duct is filled with stones, which cannot be removed, and conventional surgery cannot solve the case of diseased liver segments or narrowed bile ducts, or end-stage intrahepatic bile duct stones with portal hypertension or severe biliary cirrhosis.

A suitable liver source is sought for transplantation.

Prognosis

Cure

Intrahepatic bile duct stones are mostly benign but difficult to cure.

Early detection and treatment tend to be more effective.

If serious complications are already present at the time of detection, there are usually more serious sequelae.

In severe cases, it may lead to cholangiocarcinoma, and the cure and prognosis will be worse.

Hazards

It may cause other diseases, such as acute purulent cholangitis, bile-derived liver abscess, biliary bleeding, fibrinolytic abnormality or gallstone pancreatitis.

Daily

Daily management

Intrahepatic bile duct stones require major attention to diet in daily life.

Eat a well-balanced diet and avoid eating too greasy and high cholesterol food.

Avoid overeating and pay attention to balanced nutritional intake.

Eat more fresh fruits and vegetables.

Prevention

Intrahepatic bile duct stones are related to biliary tract infections, biliary tract parasites, anatomical variations of the bile ducts and bile stagnation, and may also be related to a diet low in protein and fat.

Reasonably adjust the diet structure to avoid low protein and low fat diet.

Actively treat biliary tract infections and cholelithiasis.

Pay attention to dietary safety and avoid foods that may contain roundworm eggs.

Strengthen physical exercise and control body weight.

Regular physical examination for early detection and early treatment.