{"type":"rich","version":"1.0","provider_name":"Transistor","provider_url":"https://transistor.fm","author_name":"Board Pearls","title":"Chapter 27, Ep 3 of 4: Duct Stones and Acute Cholangitis","html":"","width":"100%","height":180,"duration":562,"description":"Episode three takes the stone into the bile duct, and the whole problem sits on a probability question, because ERCP carries its own complication profile, headlined by post-ERCP pancreatitis. You earn the right to do an ERCP by raising the pretest probability of a retrievable stone high enough to justify the procedural risk, so high-probability patients go straight to ERCP while intermediate patients confirm the stone first with MRCP or endoscopic ultrasound. When the same stone turns septic, cholangitis runs on a hydraulic mechanism: the obstruction raises intraductal pressure and refluxes bacteria into the blood, which is why antibiotics alone cannot fix it and decompression is mandatory. The Tokyo grade scales the timing, and clinical improvement on antibiotics is never mistaken for a relieved obstruction.\n \nTopics covered\n\nPost-ERCP pancreatitis and the probability tiers\nHigh, intermediate, and low probability features\nMRCP versus endoscopic ultrasound\nLarge stones and post-cholecystectomy stones\nCholangitis and the hydraulic mechanism\nCharcot triad and Reynolds pentad\nTokyo grading and decompression timing\nEmpiric antibiotics and rescue drainage\n \n \nKey decisions\n\nHigh-probability duct stone requires any one of a stone seen on imaging, ascending cholangitis, or a bilirubin over four with a duct dilated above six millimeters, and any one of those sends the patient straight to ERCP.\nIntermediate-probability patients should not go straight to ERCP; confirm or refute the stone first with MRCP, or endoscopic ultrasound when small stones or sludge are suspected.\nMRCP misses stones under six millimeters while endoscopic ultrasound catches sludge and microlithiasis, so small-stone disease favors EUS and an anatomic duct survey favors MRCP.\nStones a centimeter or larger exceed what a conventional sphincterotomy can extract, so first-line therapy is sphincterotomy plus large-balloon dilation, with cholangioscopy-directed lithotripsy as the alternative.\nIn cholangitis,...","thumbnail_url":"https://img.transistorcdn.com/-FuAdDBcPDLhEoUmroZKtOBRvuBn_FHPpYlh41hOnU4/rs:fill:0:0:1/w:400/h:400/q:60/mb:500000/aHR0cHM6Ly9pbWct/dXBsb2FkLXByb2R1/Y3Rpb24udHJhbnNp/c3Rvci5mbS9iNzlh/ZTU4Y2MzNWExMjQ5/MjA5OWMwMmI3ZTk5/NGFiZS5wbmc.webp","thumbnail_width":300,"thumbnail_height":300}