Korean J Gastroenterol.  2018 May;71(5):247-252. 10.4166/kjg.2018.71.5.247.

Management of Intrahepatic Duct Stone

Affiliations
  • 1Division of Gastroenterology, Department of Internal Medicine, Soon Chun Hyang University Seoul Hospital, Soon Chun Hyang University College of Medicine, Seoul, Korea. swcha@schmc.ac.kr

Abstract

Intrahepatic duct (IHD) stone is the presence of calculi within the intrahepatic bile duct specifically located proximal to the confluence of the left and right hepatic ducts. This stone is characterized by its intractable nature and frequent recurrence, requiring multiple therapeutic interventions. Without proper treatment, biliary strictures and retained stones can lead to repeated episodes of cholangitis, liver abscesses, secondary biliary cirrhosis, portal hypertension, and death from sepsis or hepatic failure. The ultimate treatment goals for IHD stones are complete removal of the stone, the correction of the associated strictures, and the prevention of recurrent cholangitis. A surgical resection can satisfy the goal of treatment for hepatolithiasis, i.e., complete removal of the IHD stones, stricture, and the risk of cholangiocarcinogenesis. On the other hand, in some cases, such as bilateral IHD stones, surgery alone cannot achieve these goals. Therefore, the optimal treatments require a multidisciplinary approach, including endoscopic and radiologic interventional procedures before and/or after surgery. Percutaneous transhepatic cholangioscopic lithotomy (PTCS-L) is particularly suited for patients at poor surgical risk or who refuse surgery and those with previous biliary surgery or stones distributed in multiple segments. PTCS-L is relatively safe and effective for the treatment of IHD stones, and complete stone clearance is mandatory to reduce the sequelae of IHD stones. An IHD stricture is the main factor contributing to incomplete clearance and stone recurrence. Long-term follow-up is required because of the overall high recurrence rate of IHD stones and the association with cholangiocarcinoma.

Keyword

Intrahepatic duct stone; Hepatolithiasis; Hepatectomy; Percutaneous transhepatic cholangioscopy; Post-operative cholangioscoopy

MeSH Terms

Bile Ducts, Intrahepatic
Calculi
Cholangiocarcinoma
Cholangitis
Constriction, Pathologic
Follow-Up Studies
Hand
Hepatectomy
Hepatic Duct, Common
Humans
Hypertension, Portal
Liver Abscess
Liver Cirrhosis, Biliary
Liver Failure
Recurrence
Sepsis

Figure

  • Fig. 1. Tsunoda classification.5 Type I, no marked dilatation or strictures of intrahepatic bile ducts. Type II, diffuse dilatation of the intrahepatic biliary tree without intrahepatic duct strictures and frequently a stricture of the distal common bile duct. Type III, unilateral solitary or multiple cystic intrahepatic dilatation, frequently accompanied by stenosis of the left or right intrahepatic bile ducts. Type IV, the same attributes as type III but with bilateral involvement of hepatic lobes.

  • Fig. 2. Proposed therapeutic algorithm for the management of IHD stones. IHD, intrahepatic duct; EST-L, endoscopic sphincterotomy- lithotomy; PTCS-L, percutaneous transhepatic cholangioscopy-lithotomy; POC-L, postoperative cholangioscopy-lithotomy.


Reference

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