Management of
bile-duct obstruction
Patients with symptoms after a cholecystectomy, particularly if jaundice
is present, demand urgent investigation. Any patient who does not make an
uneventful recovery following gall-bladder surgery should be investigated by
ultrasound scanning as a matter of immediacy. If jaundice (either biochemical
or clinical) is present emergency measures are required.
The first step in management is to undertake an immediate ultrasound
scan. If there is evidence of fluid in the subhepatic space or obstruction of
the biliary tree as shown by bile-duct dilatation then an immediate ERCP should
be performed to ascertain whether a stone is present or there is obstruction of
the common bile duct due to damage at the time of surgery (Fig.
54.41).
If a stone is present immediate removal
endoscopically is indicated. If the common bile duct is obstructed by clips or
there is leakage from the biliary tree due to a cystic duct leak then a drain
should be placed in the subhepatic space percutaneously and a stent placed in
the bile duct where possible. Small leaks will usually resolve spontaneously.
Should the common bile duct be damaged the patient should be referred to an
appropriate expert for reconstruction of the duct.