COMPLEX INTRAHEPATIC LITHIASIS: A CASE STUDY ON BILIARY EXPLORATION AND BILIODIGESTIVE BYPASS (Atena Editora)

Abstract

Cholelithiasis, the presence of stones in the gallbladder, is the most prevalent disease of the biliary tract, affecting approximately 15% of the population. Its complications include cholecystitis, choledocholithiasis, and biliary pancreatitis. Intrahepatic lithiasis, less frequent in the West (0.6-1.3%), involves stones in the bile ducts within the liver and can cause bile duct stenosis, cholangitis, liver abscess, biliary cirrhosis, portal hypertension, and cholangiocarcinoma. The goal of treatment is to remove the stones and the associated infection, reduce the possibility of recurrent lithiasis, and avoid the risk of malignant transformation in cases with significant dilatation of the bile ducts. Initial treatment is endoscopic, with removal of stones in 75% of cases. However, complex presentations such as large dilatations in the bile ducts, intrahepatic lithiasis, and large stones present a challenge in terms of approach and control of complications. The case reported is of a 67-year-old female patient with pain in the right hypochondrium and cholestatic syndrome, diagnosed with choledocholithiasis, intrahepatic lithiasis and biliary tract dilation. After failed endoscopic attempts to remove the stones, surgical treatment was indicated due to the persistence and complexity of the condition. Cholecystectomy, exploration of the biliary tract and biliodigestive diversion with Roux-en-Y hepaticojejunostomy were performed to ensure adequate drainage and prevent complications such as biliary stasis and infections. The surgical approach ensures complete removal of the stones and reduces the risk of serious complications associated with intrahepatic lithiasis and choledocholithiasis. Biliodigestive diversion is indicated in selected cases and involves anastomoses such as choledochoduodenostomy and hepaticojejunostomy. We suggest hepaticojejunostomy as a preferential option because it minimizes the risk of sump syndrome and infections, as well as fewer complications associated with jejunal fistulas compared to duodenal fistulas.