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Management of Obstractive Jaundice Due to Common Bile Duct Stone in Baghdad Teaching Hospital
علاج اليرقان الانسدادي الناتج عن حصاة القناة الصفراوية المشتركة في مستشفى بغداد التعليمي

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Abstract

Background: the most common cause of obstructive jaundice is CBD stones, and these can produce significant morbidity and mortality. The management of the obstructive jaundice due to CBD stones is in evolution; several methods of investigations and treatment have been introduced, and each one has its own advantages and disadvantages.Objective: to study and evaluate the management of obstructive jaundice due to CBD stones in Baghdad teaching hospital.Patients and methods: a prospective study of 111 patients with clinical, laboratory, and imaging features suggestive of obstructive jaundice due to CBD stones who were managed in Baghdad teaching hospital over the period from January 2011 to November 2011; other 14 patients with obstructive jaundice due to other causes were excluded. . All patients were symptomatic and had abnormal liver function tests. Transabdominal US was done for all of them, MRCP for 26 patients, and EUS for 9 patients. Four patients had primary stones, 95 patients had secondary stones, 9 patients had retained stones and 3 patients had Mirizzi syndrome.Those patients were subjected to ERCP both to prove the diagnosis and extract the CBD stones. Only three patients sent directly for surgical treatment because they were diagnosed as Mirizzi syndrome. Surgical treatment also was offered for those patients in whom endoscopic management failed. Results: from the 125 patients presented with obstructive jaundice included in this study 14 patients were found to have a periampullary lesions, and they were excluded from the study, so the total number of the patients was 111; 46 males and 65 females Endoscopic management was done for 108 patients with success rate of 90%. Surgical treatment was required in 13 patients, 10 of them following failure of ERCP and the other 3 patients were those with Mirizzi syndrome. The most common complication of ERCP was acute pancreatitis and the most common cause of failure to extract the stones was the size of stone (more than 15mm) Conclusions: Endoscopic sphincterotomy and stone extraction followed by laparoscopic cholecystectomy is still considered the orthodox treatment of CBD stones. Large and multiple CBD stones are the most common causes of failure of endoscopic extraction and indication for surgical treatment. There was higher incidence of retained CBD stones in our study than what was reported in western countries, because there is no intraoperative screening to avoid missing CBD stones in our hospital.Key wards: CBD stones, endoscopic management, surgical intervention

خلفيه الموضوع: اكثر اسباب اليرقان الانسدادي هو حصا القناه الصفراء,وهذا يمكن ان يولد مضاعفاه ووفياه مهمه.معالجه اليرقان الانسدادي الناتج من حصاه ه قناه الصفراء في تطور,عده طرق تشخيصيه وعلاجيه ادخلت في هذا الموضوع وكل منها له فوائده ومضاره.هدف الدراسه:لغرض دراسه وتقييم معالجه اليرقان الانسدادي الناتج عن حصاه القناه الصفراء في مستشفى بغداد التعليمي.المرضى والوسائط :دراسه مستقبليه مكونه من 111 مريض لديهم اعراض سريريه ونتائج مختبريه وصوريه تقترح وجود يرقان انسدادي ناتج عن حصاه القناه الصفراء عولجو في مستشفى بغداد التعليمي في الفتره من كانون الثاني 2011 الى تشرين الثاني 2011 14 مريض اخر ابعدو من الدراسه بسبب ثبوت ان سبب اليرقان الانسدادي لديهم كان باسباب اخرى.العمل المبذول لكل مريض كان اخذ تاريخ المرض والفحص السريري وفحوصات مختبريه فحص الامواج فوق الصوتيه (السونار) للبطن.نفس المرضى تعرضوا لعمليه تنظير القناه الصفراء لسببين لغرض التشخيص واستخراج حصاه قناه الصفراء .مريضين فقط ارسلوا مباشره الى العلاج الجراحي كان لديهم (متلازمه ميريزي).كذالك اجريت العمليات الجراحيه للمرضى الذين فشلت لديهم المعالجه الناظوريه.النتائج:من ال125 مريض الذين لديهم يرقان انسدادي والذين انضموا لهذه الدراسه ,14مريض لديهم اسباب غير حصاه القناه الصفراء ابعدوا من هذه الدراسه, فاصبح العدد الكلي للمرضى 111 مريض46 ذكر و65 انثى .جميع المرضى ليهم اعراض سريريه ولديهم نتائج تحاليل وظائف كبد غير طبيعيه , اجري الفحص السوناري لجميع المرضى ,وفحص الرنين المغناطيسي للقنوات الصفراء والبنكرياس اجري ل26 مريض وفحص السونار عن طريق ناظور المعده والاثني عشر ل9 مرضى ,4 مرضى كان لديهم حصاه القناه الصفراء الاوليه, 95 مريض كان لديهم حصاه القناه الصفراء الثانويه , 9 مرضى كان لديهم حصاه القناه الصفراء المحفوظه , و3 مرضى لديهم (متلازمه ميريزي ).المعالجه المنظاريه اجريت ل 108 مريض نجحت في 90% من المرضى.العلاج الجراحي اجري ل 13 مريض 10 منهم بعد فشل العلاج المنظاري و3 مرضى كان لديهم (متلازمه ميريزي) .الاستنتاجات:العلاج الناظوري لاستخراج حصاه القناه الصفراء المتبوع برفع المراره ما زال الطريقه الرشيده في علاج حصاه القناه الصفراء . حصاه القناه الصفراء الكبيره وتعددها ما زالا الاسباب الاكثر شيوعا لفشل العلاج المنظاري لاستخراج حصاه القناه الصفراء والعلاج الجراحي ,في هذه الدراسه كان هنالك نسبه حصاه محفوظه في القناه الصفراء اعلى من الدراسات المذكوره في الدول الغربيه,بسبب عدم وجود فحوصات خلال العمليه تجرى لغرض تشخيص حصاه القناه الصفراء لغرض تلافي ترك حصا في القناه الصفراء في مستشفانا مفتاح الكلمات: حصاة القناة الصفراوية المشتركة، العلاج الناظوري، التداخل الجراحي

Keywords

Background: the most common cause of obstructive jaundice is CBD stones --- and these can produce significant morbidity and mortality. The management of the obstructive jaundice due to CBD stones is in evolution --- several methods of investigations and treatment have been introduced --- and each one has its own advantages and disadvantages. Objective: to study and evaluate the management of obstructive jaundice due to CBD stones in Baghdad teaching hospital. Patients and methods: a prospective study of 111 patients with clinical --- laboratory --- and imaging features suggestive of obstructive jaundice due to CBD stones who were managed in Baghdad teaching hospital over the period from January 2011 to November 2011 --- other 14 patients with obstructive jaundice due to other causes were excluded. . All patients were symptomatic and had abnormal liver function tests. Transabdominal US was done for all of them --- MRCP for 26 patients --- and EUS for 9 patients. Four patients had primary stones --- 95 patients had secondary stones --- 9 patients had retained stones and 3 patients had Mirizzi syndrome.Those patients were subjected to ERCP both to prove the diagnosis and extract the CBD stones. Only three patients sent directly for surgical treatment because they were diagnosed as Mirizzi syndrome. Surgical treatment also was offered for those patients in whom endoscopic management failed. Results: from the 125 patients presented with obstructive jaundice included in this study 14 patients were found to have a periampullary lesions --- and they were excluded from the study --- so the total number of the patients was 111 --- 46 males and 65 females Endoscopic management was done for 108 patients with success rate of 90%. Surgical treatment was required in 13 patients --- 10 of them following failure of ERCP and the other 3 patients were those with Mirizzi syndrome. The most common complication of ERCP was acute pancreatitis and the most common cause of failure to extract the stones was the size of stone --- more than 15mm Conclusions: Endoscopic sphincterotomy and stone extraction followed by laparoscopic cholecystectomy is still considered the orthodox treatment of CBD stones. Large and multiple CBD stones are the most common causes of failure of endoscopic extraction and indication for surgical treatment. There was higher incidence of retained CBD stones in our study than what was reported in western countries --- because there is no intraoperative screening to avoid missing CBD stones in our hospital. Key wards: CBD stones --- endoscopic management --- surgical intervention --- حصاة القناة الصفراوية المشتركة، العلاج الناظوري، التداخل الجراحي

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