Bile duct stones

1. Classification

- By location

• Intrahepatic bile duct stones (hepatolithiasis): stones in the right hepatic duct, left hepatic duct, and smaller intrahepatic bile ducts
• Extrahepatic bile duct stones: stones in the common bile duct

- By stone type

• Cholesterol stones
• Pigment stones: black or brown
• Black pigment stones
• Brown pigment stones
• Mixed stones (cholesterol and pigment)

2. Symptoms

• Abdominal pain: in the right upper quadrant or epigastric region, which may radiate to the back or right shoulder
• Fever: 38–39°C, often accompanied by chills
• Jaundice
• Itching
• Dark-colored urine

3. Diagnostic imaging

• Ultrasound
• Computed tomography (CT scan)
• Magnetic resonance imaging (MRI)

4. Complications

• Cholangitis
• Septic shock
• Pyogenic liver abscess
• Biliary peritonitis
• Acute pancreatitis
• Acute kidney injury
• Coagulopathy
• Hemobilia
• Cholangiocarcinoma

5. Treatment

5.1. Uncomplicated bile duct stones: stone removal

• Common bile duct exploration for stone removal with placement of a Kehr drain or primary closure of the common bile duct: open surgery or laparoscopic surgery
• ERCP: endoscopic retrograde cholangiopancreatography for stone removal
• Common bile duct stone removal through the cystic duct: performed in combination with cholecystectomy
• Percutaneous stone removal
• Percutaneous transhepatic biliary drainage (PTBD) to establish a biliary access tract
• Tract dilation
• Stone removal using a cholangioscope
• Hepatectomy for hepatolithiasis: indicated in cases of hepatic parenchymal atrophy, multiple stones, or biliary strictures
• Cutaneous biliary-enteric anastomosis: using the gallbladder or intestine for the treatment of recurrent stones or stones with a high risk of recurrence
• Cholecystocutaneous drainage using the gallbladder
• Cutaneous biliary-enteric anastomosis

5.2. Complicated bile duct stones

• This is a medical emergency requiring a combination of medical and surgical treatment.
• Medical treatment: fluid and electrolyte replacement, antibiotics, and management of underlying medical conditions
• Surgical treatment: biliary drainage for decompression
• Stone removal may be performed during the same intervention or at a later stage.

5.3. Treatment of retained stones after surgery

• Stones intentionally left during the previous surgery for subsequent removal after surgery (due to multiple stones or because the previous procedure only provided biliary decompression)
• Methods: stone removal through the Kehr tract, through a cutaneous biliary-enteric anastomosis, or percutaneous stone removal
• Timing: usually 3 weeks after the previous surgery

6. Admission and treatment process

Before surgery (day of admission):

• The treating physician will take the patient's medical history, perform a physical examination, and order relevant laboratory and diagnostic tests.
• Blood tests: creatinine, GOT, GPT, total bilirubin, direct bilirubin, lipase or amylase, albumin, electrolytes, complete blood count, coagulation tests (PT, aPTT, fibrinogen), blood type, hepatitis B and C tests, and HIV
• Chest X-ray
• Abdominal ultrasound
• Abdominal CT scan or hepatobiliary MRI if necessary
• Pre-anesthesia and perioperative assessments, as well as consultations with relevant specialties (cardiology, endocrinology, respiratory medicine…)
• The anesthesiologist will explain issues related to anesthesia.
• Surgery will be scheduled.
• The treating physician will explain the disease, treatment method, potential adverse events and surgical complications, and obtain the patient's informed consent for surgery.
• Nurses will provide instructions on diet and any medications that need to be discontinued.
• The physician will mark the surgical site.

Day of surgery:

• Usually on the second day after admission if there are no medical conditions requiring adjustment.
• The patient will be transferred to the operating room area (2nd floor) when an operating room is available.
• Change into surgical attire.
• Enter the operating room.
• Anesthesia
• Surgery
• Transfer to the recovery room.
• Care in the recovery room: approximately 2–6 hours.
• Transfer to the surgical department once the condition is stable.

After surgery:

• Patients are usually discharged 1–7 days after surgery, depending on the surgical method and the patient's condition.
• Common postoperative issues include:
• Nausea, vomiting, and dizziness due to the side effects of anesthetic medications
• Surgical wound pain
• Fever…
• Early mobilization and walking are encouraged.
• Patients may drink bird's nest beverage and eat porridge 6 hours after surgery.
• Patients may return to normal activities after 1 week, including riding a motorcycle or bicycle, jogging, and lifting heavy objects…
• Sutures are removed after 1 week–10 days.
• Follow-up and consultation with the surgeon 3 weeks after surgery.

7. Postoperative follow-up and complications

• Bleeding
• Surgical site infection
• Residual fluid collection or abscess
• Worsening cholangitis
• Biliary drainage tube obstruction
• Acute pancreatitis following ERCP
• Hollow viscus perforation
• Pleural effusion

8. When should you call your doctor?

• Persistent high fever above 39°C
• Severe abdominal pain
• Nausea and vomiting
• Abdominal distension
• Bleeding
• Chills
• Persistent cough or difficulty breathing
• Chills
• Swelling, redness, or pus from the surgical wound
• Inability to eat or drink
• Any questions or concerns related to your recovery

The information above is for reference purposes only and is not intended as medical advice. Please contact your doctor for detailed medical consultation.