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• W1987174167 abstract "To the Editor: Choledocholithiasis following cholecystec-tomy has been associated with benign postoperative bile duct strictures, remnants of nonabsorbable suture used at chole-cystectomy, and the existence of periampullary duodenal diverticula.1–3 Duodenal diverticula usually lie in close proximity to the ampulla of Vater and may increase the incidence of common duct stones by five times.2 Described here is the case of a 78-year-old woman who developed acute obstructive jaundice 52 years after a cholecystectomy, who was found to have a large periampullary diverticula and severe choledocholithiasis, and who was successfully treated with endoscopic sphincterotomy followed by extracorporeal shock wave lithotropsy. A 78-year-old woman with a history of non-insulin-dependent diabetes mellitus and hypertension presented with acute onset of severe epigastric pain and vomiting. She denied fevers, chills, hematemesis, diarrhea, acholic stools, dark urine, or pruritis. She had had on open cholecystectomy 52 years before admission for cholecystitis. She denied alcohol use or blood transfusions. On physical examination, she was afebrile and in mild distress. The sclera were icteric. Abdominal examination revealed a well healed scar and tenderness in the right upper quadrant. There were no peritoneal signs, and the stool was negative for occult blood. The rest of the physical examination was normal. Laboratory evaluation revealed normal serum electrolytes and white blood cell count. Total bilirubin was 6.2 mg/dL, with a conjugated fraction of 4.3 mg/dL. Serum liver chemistries showed an alkaline phosphatase of 386 mg/dL, aspartate aminotransferase of 96 mg/dL, and an alanine aminotransferase of 389 mg/dL. Amylase and lipase were normal. An ultrasound of the right upper quadrant showed biliary dilatation with a common duct measurement of 18 mm; numerous large stones also were visualized. The patient was taken to endoscopic retrograde cholangiopancreaticography (ERCP), which revealed numerous large stones and a dilated common bile duct (Figure 1). A large periampullary duodenal diverticula was seen endoscopically. A sphinchterotomy was performed, but because of the large number of residual stones, extracorporeal shock wave lithotropsy (ESWL) was carried out. At no time had the patient signs or symptoms of cholangitis. At follow-up ERCP, the residual fragments were removed easily, and the patient was discharged home asymptomatic with normal liver chemistries. . Endoscopic retrograde cholangiopancreatography (ERCP) showing a massively dilated common bile duct with multiple filling defects representing common duct stones. The periampullary diverticula is shown by the arrow. The formation of stones de novo in the common bile duct (choledocholithiasis) is a well established event.1 Predisposing factors to choledocholithiasis include benign posttraumatic stricture, sclerosing cholangitis, congenital cystic disease, Caroli's disease, and periampullary diverticula.1′2 Choledocholithiasis after cholecystectomy has also been reported to occur secondary to remnants of nonabsorbable suture material used for cystic duct ligature, although this is an uncommon event.3 Braasch et al. reported a series of patients who presented with symptomatic choledocholithiasis after cholecystectomy.1 However, the mean duration from surgery to symptom onset was 9 years, 1 much shorter time than the 52 years for this patient. Periampullary duodenal diverticula have been shown to be associated with a high rate of calcium bilirubinate stone formation.2,4 Hall et al.2 examined the incidence of stones and periampullary diverticula following choiecystectomy and found diverticula to occur more commonly in patients with jaundice. Furthermore, common bile duct stones post-cholecystectomy were strongly associated with the presence of a diverticulum: common duct stones were noted in 43% of patients with a diverticulum but in only 18% of patients without a diverticulum.2 They also found that choiecystectomy did not prevent choledocholithiasis in the presence of a diverticulum.2 The etiology of the formation of common duct stones in the presence of a periampullary diverticulum is thought to be caused by ascending infection of the common bile duct by beta-glucoronidase-producing bacteria.2,4 Identical bacterial flora have been recovered in the biliary tree and diverticulum in some patients.2 The stone composition of patients with diverticula is mainly calcium carbonate, not cholesterol.2,4 Intestinal beta-glucoronidase-producing bacteria split conjugated bilirubin into glucoronic acid and unconjugated bilirubin, which then combine with calcium to form insoluble calcium bilirubinate.2,4 The presence of the juxtapapillary diverticulum is thought to cause ampullary dysfunction, allowing the migration of these bacteria into the duct.2 If an older patient with a history of choiecystectomy presents with biliary pain, the possibility of a periampullary diverticulum should be kept in mind in as much as it seems to increase the likelihood of common duct stone formation.2,4 The history of a remote choiecystectomy, 52 years in this patient, should not dissuade the clinician from considering the diagnosis of choledocholithiasis. This case illustrates successful nonoperative management of severe choledocholithiasis by ERCP with sphincterotomy and ESWL. Although the optimal treatment of this clinical situation remains to be resolved, consideration of nonoperative treatment in an older patient deserves consideration." @default.
• W1987174167 created "2016-06-24" @default.
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• W1987174167 date "1995-11-01" @default.
• W1987174167 modified "2023-09-25" @default.
• W1987174167 title "CHOLEDOCHOLITHIASIS CAUSING OBSTRUCTIVE JAUNDICE 52 YEARS AFTER CHOLECYSTECTOMY" @default.
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• W1987174167 doi "https://doi.org/10.1111/j.1532-5415.1995.tb07416.x" @default.
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