Treatment of bile duct stones endoscopically and by extracorporeal shock waves

Endoscopic sphi ncterotomy was performed in a 68-year-old female patient with multiple stones in the common bile duct and cholangitis. Because the extraction of all the stones was not achieved extracorporeal lithotripsy was performed. Following fragmentation all the residual stones passed spontaneously and no complication occurred.


R E1AINED BILIARY STON ES ARE DIS•
covrred following cholecystectomy in at lrast 3 to 5% of patie nts ( l ).When endo~op1C sphinctcrotomy was first introduced 15 years ago, it was primarily used for rrmoval of these retain ed com• mon bile duct stones in high risk indivtduals Since then endoscopic sphinc• terotomy has become widely used in an lncreasmg number of biliary and pancreatic disorders (2, > ).
Although endoscopic sphincterotomy 'th M Onl' removal has been success( u I the maiority (80 to 95°io) of attempts, ere arecl'rtain situations which ca n in-crcasl' the failure rate and decrease the safety of the proced ure.Stone(s) large r th an 2.0 cm, s tones trapped in prox ima l (intrahepatic) ducts and long stricture of the d istal com mo n bile duct pose p a rticulnr problems (2).Occasionall y, blood , purulent bile or debris can obscure vision ca using difficulties.

CASE PRESENTATION
A 68-year-old woman was admitted with an eight day history of dull , aching, abdom in al pain rad iating into the back.The day prior to admission, she had beco ml' more nnuseated, noted a te mper- Became of the nttncks of s h arp right u pper q u ndran t abdomm al pam , a common bile duct explorauon was perfor m ed in 1974 and an und isc lo~cd number o f bile du ct scones were removed.Othe rwise, prior to adm1ss1on , there had been no change in bowel habit a nd no pain o ther than that in rhc cp1gasrnum and right upper quadrant.Stool colour was normal.The a b domin al pain was only eased with narcotic analgesics.ln addition to the previously noted operations, the patient hnd had n right modified mnstectomy performed in 1986.Just prior to this, a diagnosis of hypertension had been made.Medications on admission were rnmoxifen 10 mg bid, Aspirin 325 mg every two days and mdapamide 2.5 mg every two d ays.She was a smoke r of three-qua rters of a pack per day for the previous 50 years nnd drank infrequently.Family history was significant O n physical examination the prrtient was m,t in acute Jistres!> with stable vital signs, pulse 90/min , blood pressure of 130/90 mm Hg, temperature of16.6°C.
No jaundice, finger clubbing or skin lesions werr noted.Chest exa m identified a previous righ t mastectomy, and hilareral basal inspi ramry crackles on auscul• tarion .more pronou need on the left side On cardiova~cul ar examination.jugular venous pressure and peripheral pulses were normal as was a uscultatio n of the hear t.On abdominal examin ation , there was no tenderness to palpation.The liver edge was felt to be of normal consistency wrth a span of 10 c m .There was no palpable sp kcn or other palpabk• masses.Rccra l cxamtnation was normal.No other abnorm:1lities were detected.
At th e time ofadmission, white b lood cell count was elevated at 17,200/mm 1 with ;i he moglobin of 12.9 g/ lOO ml and increased platelets of 6 16,000/mm I with an elevated eryth rocyte sedim e nt.1tionrate of 45 mm/L.Amylase was normal ;n 36 iu/ L with a normal total bil irubin of 17 µmoll L. alkaline phosphatase was 124 iu/L.(normal, 10 to 11 5), asparrnte a minotransfera se 87 iu/ L, (norm al, 7 to 50) a nd gamma glutamyltransfernsc 14 3 iu/L (normal , less th an 40).Proth rom• b in time and parti;il thromboplasti n time were normal.An abdominal ultrasou nd w;is perfo rmed the day of admission 50 showing a dilmed common bile duct hut normal intra hepatic d ucts ( Figure I ).At le;ist two stones were seen in the com• mon bile duct on ultrawu nd ( Figu re 2 ).
The follow ing day end(,scoprc retro• grnde cholangiography (Figure 1) was performed and endoscopi c sphincterotomy w,1, carried (>Ut.One swne was removed by basket extractio n .A large amount of pus d rained from th e comnwn hile duct , therefore, n o furth er manipulation was ca r ried out and a naS()bi liar y cathe ter was rn~crted The patient wa~ monitored over the weekend \\'hik on hroad spectrum antibio ti c coverage an d a cholangiogram was per• for med three days later.At this time.three common b ile duct stones remained (Figu re 4).O n the following day.extracorporeal shock wave lithotripsy (ESWL) was carried out u sing an u n modi ficd HM -> Dornier litho1ripter wrth Z32'i shocb at 21 kV.Tlw stones were frngmcn tcd and a follow-up chola ngrogrnm the following day showed com pie re rc mo\'al of the srones ( Figure 5) Recovery was uneventfu l; the dav after the lith otripsy, alkal ine phosphatase had d ropped to 71 iu/L, aspartate aminotransfe rase had risen to 166 iu/L an d tlw tc>tal bilirubin was l'ssenriall y u nchanged at 151imol/L.At J rscha rgc, complete blood coun t iden tified a whrte blood count of9700 wirh a mild anemia of 10.5 g/ 100 ml.
The ideal ESWL app,irat us wi ll treat hnth renal and b iliary stones, providing hntl1 sonograph ic and x-ray imag111g for targeti ng (II).In the e:irly phase o( development of the method, a ll patients were tremcd under general anesthcsi;i.Presently, however.the majority of pro• ced u res is performed under in travenous analgesia ( 12).
It is est imated that by the enJ of 1987 ar least 300 patients received ESWL for biliary ~tone~.An increasing number of publications report on ,ucccssfully treat• eel crises or small grou ps o( rarients (4,6,8,10,12).The largest experience is Biliary lithotnpsy wa:, inspi re d by the success of fragmentation of kid ncy stones hy extracorporeally generate d shock waves.The method was pioneered in Munich, West Germany (4).b u r has rapidly gained popu lari ty in North America ( 5,6).Shock waves can be generated hy different methods; clccrrostauc spark discharge, clectrnm;1gnctic shock and pulsed piezoelectric shock (7,8).Large immersion water tanks have been replaced in newe r, second ge n eration models with elastic and compressible water bags, improving the convenience of th e procedure (7).Biliary lithotripsy includes treatments for boch gallbladder and com-r,.l)JI l R c!! a/ the one of the Munich group.with an excellent success rate (9).Stones could be fragmented in all but one of about 150 patients treated fo r gallbladder stone:,.Complete disappearance of che fragments might occur with in days, but after six monchs 80"., of patients with previous solitary stones showed no evidence of residuum (9).Results with multiple stones have not been as favourable, multiple treatment sessions arc sometimes necessary.Please note, there may be more answers than asked for 1n the question.

NUTRITION
I. List fou r major clinic;1I manifestation~ of vitamin A toxicity.
2. Acute zinc deficiency has been described in patients receiving parenteral nutritton.Give three clinical manifesta tions of zinc deficiency.