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What is Charcots triad? Reynolds pentad? What is their significance?

The common symptomatic manifestations of biliary tree disease are pain,


fever and jaundice. And the constellation of fever, right upper quadrant or
epigastric pain and jaundice, known as Charcots triad, suggests blockage of
biliary secretion from the liver, not just the gallbladder.
As illness progress, addition of hypotension and altered mental status,
known as Reynolds pentad, patients will demonstrate systemic
manifestation of shock from biliary origin.
Charcots triad is seen in about 2/3 of patients with Ascending cholangitis,
which is an ascending bacterial infection associated with partial or complete
obstruction of the bile duct.
Hepatic bile is sterile and bile in the bile ducts is kept sterile by 1. Continuous
bile flow and, 2. By the presence of antibacterial substance in the bile such
as immunoglobulin. Mechanical hindrance to the bile flow will facilitate
bacterial contamination.
If left untreated, it may progress to septic shock. The addition of hypotension
and mental status change, both evidence of shock, to Charcots triad,
makes the Reynolds pentad.

What antibiotic will you give?

Antibiotics given should cover gram-negative aerobes as well as anaerobes.


A third generation cephalosporin with good coverage or a second generation
cephalosporin combined with metronidazole is a typical regimen.
For patients with allergies to cephalosporin, aminoglycoside with
metronidazole is an alternative.

What is Common Bile Duct Exploration? Choledochoscope? T-tube


choledochotomy? How are they performed and their indications?
Common Bile Duct Exploration

Laparoscopic CBD exploration can be performed in an attempt to manage all


calculous biliary tract disease in one setting, without the need for an additional
anesthetic or procedure.

1. With common bile duct stone identified fluoroscopically and if the stones in
the duct are small, they may sometimes be flushed into the duodenum with
saline irrigation via the cholangiography catheter after the sphincter of Oddi
has been relaxed with glucagon.
2. If this technique fails to remove the stone, a balloon catheter or wire basket
can be passed via the cystic duct and down the common bile duct, where it
is inflated and withdrawn to attempt stone extraction.
3. If still unsuccessful, flexible choledochoscopy is indicated.
The two common approaches to explore the common bile duct for stone removal
includes:

Transcystic approach
Via choledochotomy

Transcystic approach

At the completion of the cholangiography, a wire is fed down the cystic duct
into the common bile duct. Through a Seldinger technique or use of a balloon
catheter, the cystic duct is gently dilated to
allow passage of flexible choledochoscope. With
the surgeon feeding the choledochoscope into
the cystic duct and the assistant adjusting the
tip of the scope, the flexible choledochoscope
is advanced into the distal bile duct. With
identification of the offending stone, a wire
basket is passed to ensnare the stone,
withdrawing it and the choledochoscope
together.

Contraindications to transcystic approach:

Numerous, more than 8 stones


Stone larger than 1 cm
Cystic duct that does not allow dilation and
choledochoscope passage.
Stones in the commoN hepatic duct above the
duct insertion are not accessible through
transcystic approach.

Choledochotomy approach

A longitudinal inision is made in the common


bile duct itself. To expose the CBD, two stay sutures are placed on either side
of the planned choledochotomy.
The size of incision should be at least as large as the
diameter of the largest stone.
The choledochoscope is then fed down into the distal
bile duct and stone extraction is performed as
described in the transcystic approach.
At the completion of the exploration, a T-tube should
be placed via the choledochotomy and bile duct
closed using 4-0 absorbable sutures.

Contraindication:

Small-caliber bile duct (<6mm), which could be


strictured with closure

Advantage of Common Bile Duct Exploration:

1. 75-95% success rate at stone clearance, which is comparable to laparoscopic


cholecystectomy, followed by postoperative ERCP.
2. Shorter hospital stay

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