Calculus of the biliary tract
Which are the symptoms?
- Pain (biliary colic); although gallstones can migrate into the duodenum without giving symptoms, in the vast majority of cases, they cause a sudden pain in the upper and right part of the abdomen that can then last from a few minutes to hours, be intermittent and radiate to the right side as well as being associated with other symptoms;
- Fever; in particular, fever with chills is observed for bacterial infection of the bile that stagnates when stones obstruct, even temporarily, the bile ducts (acute cholangitis);
- Jaundice; it is an expression of complete obstruction of the main biliary tract by stones.
How is it diagnosed?
Diagnosis is made with a blood test allowing for the dosage of liver enzymes and the identification of stones by abdominal ultrasound. While the latter can easily allow you to identify stones when they are present in the gallbladder, it is not so when they are located in the biliary tract, especially if they are small in size.
In doubtful cases (suspected gallstones), i.e. when, in addition to the symptoms, there is dilatation of the bile ducts on ultrasound and/or a persistent increase of liver enzymes in the blood, a cholangio-magnetic resonance imaging (cholangio-RM) or an eco-endoscopy is indicated, the latter also when the cholangio-RM does not allow to make the diagnosis.
How is it treated?
The removal of stones from the gallbladder is accomplished through cholecystectomy, usually performed laparoscopically (VLC). Instead, stone removal from the biliary tract is commonly performed through an endoscopic procedure called endoscopic retrograde cholangio-pancreatography (ERCP). Through this procedure, stones are extracted from the biliary tract by performing what is known as a biliary sphincterotomy, a small cut in Oddi's sphincter, a muscular structure located where the main biliary route enters the duodenum. When stones are large and cannot be extracted with standard methods (basket or balloon), they can be fragmented with laser or electrohydraulic probes under direct endoscopic vision of the stones (cholangioscopy with lithotripsy). In the presence of biliary tract stones complicated by cholangitis, in addition to supportive medical therapy, including antibiotic therapy, the goal of ERCP is to remove the stones as soon as possible. When bile duct stones are associated with the presence of stones in the gallbladder (cholelithiasis), ERCP is usually performed before cholecystectom. Calculi located in the intra-hepatic biliary tract are more difficult to remove with ERCP than calculi in the extra-hepatic biliary tract. If unsuccessful, removal of intrahepatic stones by radiological means, using percutaneous trans-hepatic cholangiography (PTC), may be used. Surgery is limited to cases that cannot be resolved with ERCP and PTC.