Effect of Saline Irrigation to DEcrease Rate Of Residual Common Bile Duct Stones
Effect of Saline Irrigation to DEcrease Rate Of Residual Common Bile Duct Stones
In recent years, endoscopic sphincterotomy and stone extraction are standard procedures for
 the removal of bile duct stones.

 After procedures, there are some complications such as stone recurrence, papillary stenosis,
 cholangitis and liver abscess. These recurrent symptomatic bile duct stones, despite
 increasing experience and success with the procedure, occur in 4% to 24% of patients.

 Gallbladder stone, pneumobilia and many other various factors are known to be associated with
 CBD stone recurrence. Lithotripsy was also related to the development of recurrent stones. It
 is natural that small stone fragments left after lithotripsy may act as nidi for stone
 recurrence.

 Small remaining stone could not be completely detected only using ERCP stone removal and
 remaining stone removal can reduce residual and recurrent stones. Saline irrigation was
 effective immediately after ERCP stone removal to remove remaining small stones.

 Saline irrigation has many advantages such as easy to treatment during ERCP stone removal,
 almost no additional cost and rare side effect. This study The authors expect this study is a
 remarkable role of ERCP stone removal procedure.
CBD stones are defined as the occurrence of stones in the bile ducts. CBD stone usually
 causes biliary pain and jaundice, whereas obstruction that develops gradually over several
 months may manifest initially as pruritus or jaundice alone.

 Unlike stones in the gallbladder, CBD stones cause symptoms, tend to present as
 life-threatening complications such as cholangitis and acute pancreatitis. Given its
 propensity to result in these serious complications, choledocholithiasis warrants treatment
 in nearly all cases In 2010, guideline for the risk and treatment of choledocholithiasis was
 published. The most predictive variables seem to be cholangitis, a bilirubin level higher
 than 1.7 mg/dL, and a dilated CBD on US. The presence of 2 or more of these variables results
 in a high probability of a CBD stone. Advanced age (older than 55 years), elevation of a
 liver biochemical test result other than bilirubin, and pancreatitis are less robust
 predictors for choledocholithiasis.

 There are various ways of non invasive imaging diagnosis of CBD stone. The sensitivity of
 transabdominal US and conventional computed tomography (CT) in the detection of biliary
 stones is variable, ranging from 20% to 80% and from 23% to 85%, respectively. MRCP had
 sensitivity 92-93%, specificity 97-98%. Although MRCP is most excellent in diagnosis, the
 sensitivity is reduced 33-71% at diagnosis of small stones(less than 5mm) An ERCP has
 traditionally been considered the evaluation of biliary-tract diseases. This modality is very
 sensitive (90%) and specific (98%) in detecting CBD stone. EUS for the diagnosis of CBD stone
 reports widely varying sensitivities of 71% to 100% and specificities of 67% to 100%. Some
 papers report that intraductal ultrasound(IDUS) is very sensitive(97-100%). However, this is
 expensive and requires the fully-experienced endoscopist, so, it is difficult to use that.

 In recent years, endoscopic sphincterotomy and stone extraction are standard procedures for
 the removal of bile duct stones. After procedures, there are some complications such as stone
 recurrence, papillary stenosis, cholangitis and liver abscess. These recurrent symptomatic
 bile duct stones, despite increasing experience and success with the procedure, occur in 4%
 to 24% of patients.

 Retained stone is defined as incomplete stone removal during ERCP, otherwise recurrent stone
 is defined as recurrence stone after complete stone removal. A criterion to distinguish
 between the two is stones rediscovery time after ERCP stone removal. Typically, bile duct
 stones found 6 months or more after endoscopic retrograde cholangiopancreatography (ERCP)
 generally are considered recurrent, as opposed to retained Gallbladder stone, pneumobilia and
 many other various factors are known to be associated with CBD stone recurrence. Lithotripsy
 was also related to the development of recurrent stones. It is natural that small stone
 fragments left after lithotripsy may act as nidi for stone recurrence.

 For this reason, many studies that reduce the residual and recurrence CBD stones have been
 performed. Before procedures, MRCP, CT and EUS are performed to identify the exact location
 of stones. Many studies demonstrated that residual stone clearance with ENBD, EUS or IDUS
 immediately after ERCP stone removal are useful in reducing the recurrence.

 However, cholangiogram with ENBD or using EUS after ERCP stone removal increases the duration
 of hospital stay, cost and the patient's discomfort. Until now, non-invasive, time reduced,
 cheap and simply way was unknown.

 Recently, two different studies were published. Using IDUS could effectively find residual
 CBD stones that persisted after EST and balloon and basket extraction. Furthermore, normal
 saline irrigation of CBD after stone removal appeared useful in clearing residual small
 stones. These procedures could reduce the retained and recurrent stone Another study showed
 that additional IDUS to confirm complete stone clearance after ERCP with basket stone removal
 significantly decreases the early recurrence rate of common bile duct stones.

 These studies demonstrated that small remaining stone could not be completely detected only
 using ERCP stone removal and remaining stone removal can reduce residual and recurrent
 stones. Saline irrigation was effective immediately after ERCP stone removal to remove
 remaining small stones .

 However, prospective study that saline irrigation without EUS or IDUS can reduce recurrent
 CBD stones after ERCP stone removal does not yet. Saline irrigation has many advantages such
 as easy to treatment during ERCP stone removal, almost no additional cost and rare side
 effect. This study The authors expect this study is a remarkable role of ERCP stone removal
 procedure.
Inclusion Criteria:

 -  The patients were treated with CBD stone removal during therapeutic ERCP after finding
 CBD stones with CT, ultrasound or MRCP.

 -  The patients were treated with CBD stone removal during diagnostic ERCP because of
 cholangitis or cholecystitis.

 Exclusion Criteria:

 -  Hemodynamic instability

 -  Younger than 18

 -  Mental illness

 -  Received previous CBD stone removal

 -  Hemolytic anemia, IHD stone, parasites in hepatobiliary system

 -  Genetic, autoimmune, congenital biliary disorder

 -  Liver or biliary surgery except cholecystectomy

 -  Pancreatic cancer, cholangiocarcinoma, ampulla of vater cancer