49 year old female with epigastric pain

Juanita Halls MDApril 27, 2005

Case

49 year old female with history of Hodgkin’s lymphoma, breast cancer and valvular heart disease with CHF presents with epigastric pain

S/p splenectomy and XRT 1977S/p cholecystectomy 1990S/p Mastectomy, XRT and chemo 1998S/p pacemaker 2002

Meds: FurosamideLosartanSpironolactoneASATamoxifen

4/28: PE visitROS: “stomach pain”, intermittent, worse after eating, better lying

down, in past responded to ranitidine. Treated with ranitidine 150 bid

5/7: took ranitidine 3 days- side effects so stopped, epigastric pain better

6/7: pain recurredtreated with Prilosec

Called 2 weeks later and pain resolved

7/2: Epigastric pain worse, some nausea

Prilosec increased to bid

8/27: Had quit all caffeine, off Prilosec and no pain

9/14: 24 hours of epigastric pain after onion rings, cheese burger and a

beer on 9/5 now intermittent pain occ radiates

to backno nausea/vomiting/ diarrhea

VS: 137# BP 102/65 HR 65 RR 12 Afebrile

Abd: Normal BS. Surgical scars.Soft. Mild tender LUQ. No rebound or guarding. No hepatomegaly or masses

Labs:

Date Bili Alk phos ALT AST8/4 0.2 91 *139 *598/26 73 49 36

What is your differential diagnosis?

What additional tests would you order?

Differential diagnosis

GERDGastritisPUDPancreatitisHepatitisPartial SBORecurrent lymphomaRecurrent breast cancer

Labs:Date Bili Alk phos GGT ALT AST

9/14 128 *379 *263 *1719/27 0.2 *144 57 37

9/14 amylase = 54 lipase = 1969/27 Hepatitis A, B and C = negative

9/24 Abdominal CT = negativeUpper endoscopy pending

What is your differential now?

What would you do next?

A diagnostic test was ordered.

ERCP requested - done October 4

CBD - medium sized filling defects

Sphincterotomy performed:several soft yellow stones and stone material removed

Cholangiogram: no residual filling defects

Objectives

Common bile duct stones:– Detection– Incidence– Etiology– Risks– Treatment

CBD Stones

• Concomitant gallbladder and CBD stones

• Post cholecystectomy CBD stones– Retained– Recurrent

Suspect CBD stones

• Classic obstructive symptoms

• fever, RUQ pain, jaundice

• Recurrent symptoms after cholecystectomy

• Pancreatitis

Suspect CBD stones

•Hepatic biochemical tests • increased bili (> 2mg)• alk phosphatase (>150)• transaminases (2X normal)

• RUQ ultrasound or CT scan• dilated CBD

Detection of CBD stones

• RUQ ultrasound (sens 18-74%)• CT scan (sensi 76-90%)• IV cholangiography• Intraoperative cholangiography• Intraoperative CBD exploration

Detection of CBD stones

• ERCP (Endoscopic retrograde cholangiography)

– Gold standard for detection and exclusion of CBD stones

– Diagnostic and therapeutic

– Failure to cannulate about 5 %

– Serious Risks about 5 %: •Pancreatitis, perforation, cholangitis, bleeding,

sepsis, death

ERCP

(A) Single small bile duct stone with sphincterotome in position.

(B) Clear bile duct after sphincterotomy and stone extraction.

Detection of CBD stones

• MRCP (Magnetic resonance cholangiopancreatography)– Non-invasive– Detect stones as small as 2 mm– Sens 90-100% and spec 92-100% are close to

ERCP– Useful to exclude CBD stones and avoid ERCP

or an intraoperative evaluation of CBD

Gastrointest Endosc 56(6 suppl); S178-82, 2002

MRCP

Patient with abdominal pain and elevated alkaline phosphatase.

ARROW = 1.4 cm, well-defined, low-signal intensity stone in the dilated distal common bile duct. ARROWHEAD = The normal-caliber pancreatic duct.

Study (Surg Lap Endosc 8:349,

1998 )

316 patients having laparoscopic cholecystectomy

63 patients had increased bili, alk phos or GGT or dilated CBD on US and had ERCP

12 (3.8 %) had CBD stone

Study (continued)

3 year f/u of 253 patients:

6 (2.3%) had retained CBD stone

4/4 with symptoms – jaundice/biliary colic/abn labs

2/4 with abn labs but asx

Incidence of CBD stones

At time of cholecystectomy:2.5 – 10 % (mean 6 %)

Undetected retained CBD stones:

1-3 % over 3 years

Recurrence of CBD stones:24% over 15-17 years

Surg Lap Endosc 8:349, 1998 Gastrointest Endosc 44:643, 1996

Why do CBD stones form?

• Passed into CBD from gallbladder

• Form in the CBD:– Bacteria in biliary tree and stasis promote

stone formation

• ERCP may increase bacterial contamination but should decrease stasis

Risks of Common Bile Duct stones

(choledocholithiasis)

Increased risk of:

•cholangitis•pancreatitis•biliary obstruction

Treatment of CBD stones

Endoscopic sphincterotomy (ES)

If concomitant gallstones:Laparoscopic cholecystectomy 48 hours later

Endoscopic sphincterotomy

Procedure:

• Cannulate CBD with sphincterotome• Cut Sphincter of Oddi• Remove stones with basket or balloon• If extraction fails use lithotripsy: mechanical, extracorporeal shock wave, laser, electrohydraulic, chemical

Spincterotomy

ERCP and ES

(A) Stone impacted in mid bile duct. (B) Mechanical lithotripsy after sphincterotomy. (C) Completion cholangiogram after stone

extraction

Basket extraction of multiple bile duct stones after endoscopic sphincterotomy.

ES

Spincterotomy

Spincterotomy

Spincterotomy

Spincterotomy

Gallstone being removed

Gallstones being removed

Gallstones being removed

Endoscopic sphincterotomy

Complication rate 5 – 10 %• Pancreatitis• Bleeding• Cholangitis• Retroperitoneal perforation

Mortality 0 - 0.4 %

NEJM 1996;335:909 (2400 patients – 17 sites)Ann Surg 1998;201-4 (1900 patients – 7 sites)

Summary

• CBD stones are fairly common• Suspect if symptoms of biliary

obstruction and/or abnormal Bili/transaminases and/or abnormal US

• Diagnose with MRCP or ERCP• Treat with endoscopic

sphincterotomy