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Okay, so let's talk about Choledocholithiasis.

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3 00:00:03,570 --> 00:00:05,580 About 20% of patients who undergo a

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cholecystectomy for gallstones may have choledocholithiasis.

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Biliary colic is extremely painful, and obviously

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from this image you can tell it's been the

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scourge of humankind for a very long time.

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And as this colicky pain in your right

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upper quadrant progresses, the patient

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may just be with unyielding pain.

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So it can be very hard to image these patients.

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They are given a lot of sedatives, or

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morphine, or various kinds of

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painkillers, which is very helpful.

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You can also have a risk of getting ascending

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cholangitis if you're somebody who has an obstructing

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gallstone, and that can be a nidus for sepsis.

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So that's very unfortunate.

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And then, uh, these patients

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frequently come in with jaundice.

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They are the ones who are jaundiced,

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a little bit yellow with their pain.

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Take the painful jaundice again;

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never go with painless jaundice.

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That's bad.

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And it can result in acute pancreatitis

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when you obstruct the pancreatic duct.

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And we'll be seeing that in a little while.

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In general, if your patient has a bilirubin

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of greater than three to four milligrams per

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deciliter, that's an indication that there

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is an obstructive biliary process going on.

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So in those patients, you really need to, if

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they have cholecystitis, if they have elevated

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bilirubin, you wanna go on to either getting the

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MRCP, or the patient should maybe even get an ERCP.

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Sometimes it can be hard to see the choledocholithiasis,

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and especially in a patient who isn't

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allowing for that really deep interrogation.

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With your ultrasound probe though, you're

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gonna be really good, and you're gonna look

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at every single sweep, especially in any

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common bile duct more than six millimeters.

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You're gonna look really carefully at the

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sweep as far as you can, because of course

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your technologists are busy, and they're

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having the hardest time getting those images.

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It's on you to look at all of them and

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try to find that obstructing stone.

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So that you don't have to go into an MRCP if you

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have an obstructing stone in the common bile duct.

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It's an indication for an

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ERCP prior to cholecystectomy.

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In our hospital, we don't do

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a TTU injection any longer.

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We always get an ERCP, but then

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you're bringing in a GI doctor who is.

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Very comfortably asleep.

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So you need to do that knowing you have a stone,

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knowing they have O.R. for intervention, knowing that

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patient needs a sphincterotomy, and a delivery of

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that stone because they are usually in exquisite pain.

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Let's talk about some of the

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findings we saw of these stones.

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So our patient on CT scan had

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what's called the rim sign.

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I always like the spinning rims or crescent sign,

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'cause sometimes we like things to be focal or target.

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There's a million ways to say this,

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but these can be subtle on imaging.

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So you're always gonna look for that.

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Crescent of bile around a stone.

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If it's not calcified, that can be an indication.

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Again, a beautiful crescent around the

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stone in the common bile duct on an MRCP.

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You know, at times you actually have a

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calcified stone, should you get so lucky.

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That is very convincing for all of your referring

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physicians, but I can tell you sometimes

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those surgery residents are going to try to

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question whether or not this is a true stone.

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You have to really be able to convince them that

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this is a sign in radiology that we're familiar

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with, and we know that that's a choledocholithiasis, and that

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patient needs to go on to MRCP, and

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potentially a cholecystectomy at some point very soon.