Hepatolithiasis (stones in the liver):

Hepatolithiasis  is the presence of stones in the biliary ducts of the liver proximal to the confluence of the right and left hepatic ducts, irrespective of the co-existence of stones in the  gall bladder or common bile duct (CBD) . It is an emerging diseases pose a therapeutic challenge to doctors. It is rare in Western countries but prevalent in  Asia-Pacific region.. Intrahepatic stones occur more commonly in the 5th and 6th decades
The aetiology of hepatolithiasis is not fully understood, but genetic, dietary and environmental factors are thought to be contributory. Malnutrition,low socioeconomic and poor hygienic conditions are associated with a high incidence of intrahepatic stones. However, concomitant intrahepatic and extrahepatic stones occur commonly in older age groups (7th and 8th decades) and are found in approximately 70% of all hepatolithiasis.. Intrahepatic stone formation is most commonly associated with bile stasis caused by postoperative strictures, sclerosing cholangitis, Caroli’s disease or neoplasms, that result in biliary stenosis and stasis. Although hepatolithiasis is often thought to be associated with parasitic infections.   Infections with Clonorchis  sinensis and Ascaris lumbricoides are often  seen with  hepatolithiasis .
Recurrent abdominal pain, fever and jaundice (Recurrent pyogenic cholangitis,RPC) are the common symptoms.
Imaging  play a vital role in diagnosis and preoperative evaluation. Abdominal ultrasound and MRCP are the principal non invasive modality.CT scan is  helpful to detect associated mass lesion (cholangio carcinoma) of liver and biliary system.  ERCP can evaluate the extrahepatic biliary system and can offer impression about the status of hepatic dutal confluence. Tumour marker as CA 19-9 is helpful for detection associated malignancy.

Surgery remains the definitive treatment for hepatolithiasis.  Complete removal of the diseased lobe or segment is crucial to prevent recurrence and progressive liver disease The surgical approach to hepatolithiasis   typically involves the removal of the affected segment(s). Hepatectomy removes stones, eliminates strictures and the consequent bile stasis which is responsible for stone formation, and eradicates the risk of cholangiocarcinoma;
Following hepatic resection, Roux-en-Y hepatico jejunostomy to be done for continuous passage of bile. A subcutaneous loop of jejunum (Hutson access loop) may be fashioned  for interventional access as an additional approach to residual or recurrent stone.

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