2010年3月专题讲座CBDS的处理策略.ppt

Common Bile Duct Stones- Management Options 解放军324医院肝胆外科 张丰深 Gallstones Incidence 12% men and 24% women (from autopsy study in UK) 10-30% of gallstones will become symptomatic (1-2% per year) Incidence of CBD stones found before or during cholecystectomy 12% Composition Cholesterol (70-80%) Uncommonly pure cholesterol stones (10%) Most have calcium salts in their centre (90%) and 10% of these have enough calcium to be radioopaque Pigment (20-30%) BLACK-secondary stones associated with haemolysis or cirrhosis BROWN-primary stones associated with bile stasis or infection Classification Primary Stones (5%) Form de novo in CBD Related to biliary stasis and infection Tend to be brown pigment stones Secondary Stones (95%) Formed in gallbladder Tend to be cholesterol stones Classification Retained 2 yrs post cholecystectomy Recurrent 2yrs post cholecystectomy Presentation Incidental findings at cholecystectomy Biliary colic Jaundice Pancreatitis Cholangitis The 4 main liver enzymes  毛远丽, 刘志国, 孙志强, 等. 检验与临床诊断-肝病分册. 北京: 人民军医出版社, 2006:131-210 Risk stratification Risk Stratification Risk stratification High risk if-CBD 6mm -2 or more abnormal LFTs -cholecystitis/pancreatitis ? Preoperative ERCP Intermediate risk-MRCP Low risk-USS then LC Imaging Plain x-ray Ultrasound CT MRCP ERCP Ultrasound Most widely used Easy to perform Causes little discomfort Avoid irradiation and contrast media High reliability of diagnosing gallbladder stones (95%) Variable reliability of detecting CBD stones 23%-80% depends on body habitus and experience of sonographer Endoscopic ultrasound Studies using EUS to evaluate prior to ERCP Avoids cannulation of papilla and avoids the risk of cholangitis and pancreatitis Sensitivity 93% Specificity 97% Approaches ERCP with experience CT Sensitivity for CBD stones causing obstructive jaundice 75% Stones usually isodense wi