NMS. Casos Clínicos

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Chapter 7 ♦ Pancreatic and Hepatic Disorders

Q: How do the following situations influence the proposed management?

Case Variation 7.9.1. Previous cholecystectomy ◆ ◆ If the patient has had a recent cholecystectomy, there is a possibility that the patient has a retained stone in the CBD. An RUQ ultrasound is appropriate; if it is positive, attempted ERCP or percutaneous transhepatic cholangiography with stone extraction is necessary. If this procedure is not successful, the patient should return to the operating room, where bile duct exploration can be performed. ◆ ◆ The patient may also have a diagnosis of a biliary stricture resulting from an injury that occurred during cholecystectomy. The evaluation is the same, but the treatment is surgical exploration and bypass of the stricture, usually with a hepaticojejunostomy (Figs. 7-9 and 7-10). Endoscopic dilatation is another option for treatment, although studies have found that it is less beneficial. A common duct stone occurring within 2 years after a cholecystectomy is termed a retained stone, whereas a stone appearing after 2 years is termed a primary CBD stone.

Figure 7-9: Cholangiogram of a distal bile duct stricture. The arrows indicate the area of the stricture. This stricture could be a benign scar or a malignant tumor. SAMPLE