Choledocholithiasis Cholangitis Normal Abnormal Choledocholithias occurs when gallstones become stuck in the common bile duct, which connects the gallbladder and pancreas to the intestine. Cholangitis occurs when the common bile duct becomes infected. Sudden, severe pain in middle upper abdomen Pain may radiate to right shoulder Occasionally painless Fever Chills Nausea/vomiting Severe case Confusion Lethargy Low Blood Pressure Examination: Tenderness in middle upper abdomen Yellow skin or eyes Laboratory Findings: Elevated Bilirubin level Bilirubin in urine Elevated Alkaline phosphatase Amylase may be elevated ALT, AST (liver tests) may be elevated Prolonged Prothrombin time may occur Imaging: Ultrasound CT scan Radio-nuclide scan ERCP (test passing a scope down the esophagus and into the opening of the common bile duct)-ERCP can be used remove an obstructed stone. Antibiotics intravenously Vitamin K if clotting problems are present Stone removal by ERCP (see above) Lithotripsy (sound waves used to break apart) may be useful in some cases. Biliary stenting (drainage tube placed in common bile duct) if necessary Surgery if necessary Biliary Cirrhosis -- permanent damage to liver can occur especially if untreated. Bleeding problems -- because the liver's ability to make clotting factors is damaged. Pancreatic Cancer Cancer in common duct Gallbladder Cancer Primary biliary Cirrhosis Sclerosing Cholangitis Hepatocellular Cancer