Common bile duct (CBD) stone disease

The common bile duct (CBD) is the tube that connects gall bladder to the upper part of the small intestine (the duodenum). The function of CBD is to carry bile from the gallbladder and empty it into the duodenum. CBD is the distal continuation of the common hepatic duct, the tube that carries bile from the liver to the gall bladder.Gall bladder along with its duct (cystic duct), common hepatic duct, and CBD comprises of the ‘biliary system’.

Presence of stones in CBD is known as CBD stones or choledocholithiasis. There are two mechanisms of CBD stones:

• Gallstones can sometimes come out of gall bladder into the CBD, and may get stuck there. About 10%-20% patients have concomitant CBD stones.
• Occasionally stone may form de novo in the CBD. This usually occurs if CBD is narrow due to stricture.

What is the treatment for CBD stones?

Symptoms of choledocholithiasis include pain in the upper abdomen, jaundice, and occasionally fever. The presence of fever indicates the presence of infection in the bile ducts known as cholangitis, which is life threatening. Rarely the CBD stone may also obstruct the opening of the pancreatic duct because these ducts are usually connected. This may cause acute pancreatitis, which is another serious disease manifesting as severe pain, vomiting, fever, and distension.

What is the treatment for CBD stones?

CBD stones have to be physically removed and there is no medicine or drugs that can remove or dissolve these stones. The physical removal of CBD stones may be accomplished either by endoscopic method (with or without lithotripsy) or by surgical method (traditional or laparoscopic).

How are CBD stones removed endoscopically?

The most widely used method for treating CBD stones is their endoscopic removal by ‘endoscopic retrograde cholangiopancreatography (ERCP)’. A special type of endoscope known as side-viewing endoscope is introduced through the mouth and its tip is positioned in the first part of small intestine (duodenum) near the opening of CBD. From the tip of endoscope a catheter is introduced into the CBD through which a dye is injected. This dye opacifies the entire CBD as seen by fluoroscopically and the stone become visible as filling defect in the CBD. Subsequently a wire basket is introduced in the CBD which catches the stones and brings it out of CBD into the duodenum from where it can be taken out. To aid the extraction of stone from the CBD a small cut is made at the opening of CBD to enlarge it so that stone can be extracted easily. To completely clear the CBD a special balloon is sweeped in the CBD to remove any stone particles.

Obstructive jaundice

Obstructive jaundice is a particular type of jaundice and occurs when the essential flow of bile to the intestine is blocked and remains in the bloodstream. This might be due to blocked bile ducts caused by gallstones, or tumours of the bile duct which can block the area where the bile duct meets the duodenum. These may be cancerous.

Pancreatic cancer can also be a cause of blockages as it often occurs near to the ampulla of Vater, the tube which joins the pancreas gland to the duodenum

Other conditions that can cause obstructive jaundice include those that cause pressure on the bile duct such as swelling of lymph glands, scar tissue (from previous infections or surgery), or a cyst, possibly of the pancreas.

What are the symptoms of obstructive jaundice?

Symptoms of obstructive jaundice include yellowing of the skin and whites of the eyes; paler stools and darker urine; and intense itching. Other symptoms vary, depending on the underlying cause of the obstruction although you may also feel tired.

Causes of obstructive jaundice

Obstructive jaundice is a condition in which there is a blockage of the flow of bile out of the liver. This results in redirection of excess bile and its by-products into the blood, and bile excretion from the body is incomplete. Bilirubin, a component of bile, is yellow, which gives the characteristic yellow appearance of jaundice in the skin, eyes, and mucous membranes.

Obstructive jaundice is caused by conditions that block the normal flow of bile from the liver into the intestines including:

The most common cause of obstructive jaundice is the presence of stones in CBD (choledocholithiasis). Other causes of obstructive jaundice are tumors, trauma, cysts, and inflammation in the bile ducts.

• Cholelithiasis (gallstones)
• Biliary stricture (narrowing of the bile duct)
• Cholangitis (infection or inflammation of the common bile duct)
• Congenital structural defects
• Cysts of the bile duct
• Lymph node enlargement
• Pancreatitis
• Parasitic infection
• Trauma, including surgical complications

Risk factors for Obstructive Jaundice

A number of factors increase your risk of developing obstructive jaundice. Not all people with risk factors will get obstructive jaundice. Risk factors for obstructive jaundice include:

• Abdominal injury
• Gallstones
• Pancreatic cancer
• Tumors in the area of the common bile duct

Treatment of obstructive jaundice

Treatment depends on what is causing the obstruction; your doctor will advise you about your treatment options. However, these might include surgical resection; ERCP or a procedure known as Percutaneous Transhepatic Cholangiography (PTC) with percutaneous biliary drainage (PTBD). Essentially this allows the drainage of bile that has built up in the liver.