By Tedler D. Depaynos, MD

The lady patient who is an executive from a distant municipality has been complaining of abdominal pain and diagnosed to have gallbladder stones more than a year ago. Because of her extensive activities, the pain apparently “disappeared” and she forgot all about it. There was a similar recurrence just a month ago which was “tolerable” but it was followed by gradual yellowing of her eyes which later became generalized involving her skin. It was noticed by her co-officemates and relatives to be deepening so she was forced to go back to her original doctor in their provincial hospital. After another work-up, she was diagnosed to still have the gallbladder stones as well as stones outside it probably at the main duct where the bile passes going to the small intestines. She was advised surgery but she needed a second opinion because her doctor cannot rule out cancer causing the obstruction. If it was cancer she was adamant that she would not undergo any surgery. She then came to consult a town mate surgeon who is a close relative of her husband.
Severe pain is usually experienced by patients having inflammation of the gallbladder associated with stones. The main pathology is the obstruction of the gallbladder opening so that bile cannot exit when it contracts stimulated mainly by the intake of fatty foods which it helps to digest. When the obstruction is dislodged, the pain is relieved. The stone could either be dislodged back into the gallbladder or into the main duct called common bile duct or CBD, where the bile passes going into the small intestine or specifically the duodenum. In short this is one of the complications of gallstones, obstruction of the CBD causing Obstructive Jaundice.
Stones in the CBD could also come from the liver where in some cases stones are formed or in rare cases it could just be formed in the CBD if the patient is really a stone former. In the majority of instances, however, the stones come from the gallbladder.
When obstruction occurs, damming of the bile formed and secreted by the liver occurs. There is continuous accumulation and a retrograde flow develops distending the ducts, the gallbladder and causing enlargement of the liver. The bile then goes into the general circulatory system causing yellowing of the skin or jaundice which is progressive unless the obstruction is relieved. This is the simple patho-physiology of Obstructive Jaundice.
Obstructive Jaundice may however have other etiologies like tumors of the surrounding organs like the pancreas. Ultrasound (UTZ) or in more complicated cases, CT Scan or MRI could confirm the clinical diagnosis. These were done on this patient. This is probably the reason why her doctor in the province cannot rule out malignancy as the cause because only the UTZ is available in their locality. Fortunately, tumors were ruled out in this patient.
Treatment is obviously to relieve the obstruction but in some cases the surgery may be complicated especially if there is inflammation where the organs are swollen or there may be adhesions making the dissection difficult. Sometimes the anatomy is not what we read or see in our textbook so that the removal of the gallbladder and the stone in the CBD requires super meticulous surgery. To aid the surgeons in their dissection, special x-ray procedures are done during the actual surgery where dye is injected into the duct and x-rays are taken called Introperative -Cholangiography or IOC. In some cases, intra- operative UTZ is also done. Fortunately for this patient her gallbladder and the stones in the CBD were removed without any major complications. She was very thankful that she even doubled the usual professional fee of her town mate surgeon when she received a bill of courtesy.
Many young Gastroenterologists are now experts in diagnosing and removing or even by-passing the obstruction in the CBD. They have a “retrograde” instrument with a scope inserted thru the mouth that reaches the opening of the CBD in the small intestine or specifically duodenum thru a procedure called Endoscopic Retrograde Cholangio-Pancreatography or ERCP in short. They could visualize the duct by injecting a dye and remove any stone. They could also widen the duct opening and could even insert a stent similar to a pipe to by-pass obstruction that cannot or is difficult to be removed. This is also done under general anesthesia but surgery which may be difficult is avoided.**