The typical question goes "10 years status post cholecystectomy, a patient presents to the ER with fever, RUQ pain and jaundice; she is 62 years old".

The major difference in this case is, of course, the sepsis from ascending cholangitis and there is certainly an urgent need to drain the biliary system. Start always by the ABCs... Make sure the patient is well oxygenated, start IVF and possibly a central line. Get your labs and plain x-rays and start antibiotics. Then:

Order ultrasound to RUQ => will show dilated intrahepatic duct and may show a stone in distal CBD or a mass, etc.


Get an emergency ERCP (mainly to drain the CBD. Remove the stone or biopsy the mass...).
If this is unsuccessful, or not available:


Order PTCD (percutaneous transhepatic drainage of biliary tree).
If this is also not available, you have to operate on the patient after optimizing her medical condition in ICU.


Surgery: If you're an experienced laparoscopist, you can start it laparoscopically; otherwise, do it open. The main goal is to drain the biliary system by the safest way possible.
Your first choice should be exploration of CBD and try to extract the stone from its distal location, can use the choledochoscope. If you cannot remove the stone and the patient is sick or unstable, just put a T-tube in the CBD and close.
If the patient is stable and you decide to permanently drain the biliary system internally, you have basically two options. If there is not much scarring around the porta hepatis and you can mobilize the duodenum to reach without tension to your choledochotomy, do choledochoduodenostomy and leave the stone in situ (if you cannot remove it).

If the porta hepatis is severely "scarred down" and you cannot safely mobilize the duodenum, make a transverse incision in the second portion of the duodenum at the ampulla level and do sphincteroplasty and remove the stone (put stay sutures at 2 and 7 o'clock, then cut the ampulla at 10 o'clock and suture the duodenal wall to CBD wall on each side, then cut further and suture, etc. for a distance of 2 - 3cm) . In worst case that even with sphincteroplasty, you cannot remove the stone, close the duodenum a.


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