Intrahepatic bile duct stones refer to stones that occur above the junction of the left and right hepatic ducts. The incidence of intrahepatic bile duct stones is relatively low in foreign countries, accounting for only 1.3% in a series of 2,700 biliary tract surgeries, with most cases being secondary to gallbladder stones that migrate upward into the hepatic bile ducts. However, in China, the incidence of intrahepatic bile duct stones is higher, particularly in provinces such as Fujian, Jiangxi, and Shandong, where they can account for 30–40% of biliary tract stones. The higher incidence may be related to biliary tract infections caused by roundworms or to diets low in protein and fat. Intrahepatic bile duct stones can be widely distributed in the branches of the bile ducts in both lobes or localized to a single area, most commonly in the left lateral lobe or the right posterior lobe, possibly due to the greater curvature of the bile ducts and poor bile drainage in these regions. In a series of 92 cases of intrahepatic bile duct stones at Zhongshan Hospital, 31.3% involved stones solely in the left hepatic duct. In China, most intrahepatic bile duct stones are primary bile duct stones, primarily composed of calcium bilirubinate. Intrahepatic bile duct stones are often accompanied by extrahepatic bile duct stones.

bubble_chart Clinical Manifestations

The clinical manifestations of intrahepatic bile duct stones are highly atypical. During the intermittent phase of the disease, there may be no symptoms, or only mild upper abdominal discomfort (grade I). However, in the acute phase, symptoms of acute suppurative cholangitis or varying degrees of Charcot's triad may appear, which are mostly caused by concurrent extrahepatic bile duct stones. In patients without concurrent extrahepatic bile duct stones, when stones in one side or lobe of the intrahepatic bile ducts cause obstruction of the intrahepatic bile ducts in half of the liver or a specific liver segment, accompanied by secondary infection, systemic infection symptoms such as fear of cold and fever may occur. Even when acute severe cholangitis manifests with psychiatric symptoms and shock, patients may still exhibit significant abdominal pain and jaundice. Physical examination may reveal asymmetric liver enlargement and tenderness, often misdiagnosed as liver abscess or hepatitis. This cyclical intermittent发作 is a characteristic clinical manifestation of intrahepatic bile duct stones.

bubble_chart Diagnosis

The diagnosis of intrahepatic bile duct stones is relatively complex. In addition to the aforementioned clinical manifestations, previous surgical findings and X-ray imaging results are often the main basis for a definitive diagnosis. Among X-ray imaging techniques, direct cholangiography methods such as PTC and ERCP are primarily used, especially the former, which can clearly display the distribution of intrahepatic bile duct stones and identify the presence of intrahepatic bile duct strictures, complete obstructions, or localized dilatations. This is of great significance for diagnosis and guiding treatment. Although ultrasound (B-scan) has a lower diagnostic accuracy rate compared to PTC or ERCP and cannot provide detailed information about stone distribution, it still achieves 80% accuracy in diagnosing intrahepatic bile duct stones. Its greatest advantage is that it is a simple and non-{|###|}invasive examination, making it the preferred diagnostic method for intrahepatic bile duct stones at present. CT scans are less commonly used due to their high cost and because their diagnostic accuracy for pigment stones with low calcium content in the intrahepatic bile ducts is not significantly higher than that of ultrasound. Additionally, surgical exploration can be employed for diagnosis, involving careful intraoperative examination of the intrahepatic bile ducts, which is the most reliable diagnostic method for intrahepatic bile duct stones. During surgery, besides systematically examining the extrahepatic bile ducts, attention should also be paid to liver palpation, particularly the left lobe. Sometimes, a bimanual examination method is used to check for the presence of stones within the liver. Techniques such as stone forceps and T-tube irrigation are employed to explore the intrahepatic bile ducts. Intraoperative cholangiography is often a definitive diagnostic tool for intrahepatic bile duct stones and can guide and select surgical approaches. Intraoperative choledochoscopy allows direct visualization of stones within the branches of the intrahepatic bile ducts and, in some cases, enables stone extraction using tools like stone baskets and balloon catheters under choledochoscopic guidance.

bubble_chart Treatment Measures

The treatment of intrahepatic bile duct stones is still primarily surgical, with relatively good outcomes. However, since the lesions of intrahepatic bile duct stones cannot be completely resolved, especially in cases of stones in the right hepatic duct branches accompanied by bile duct strictures, the surgical efficacy remains unsatisfactory in 20–30% of cases. Therefore, postoperative integration of Chinese and Western medicine drug therapy is still necessary and should not be neglected. **Principles of surgical treatment:** 1. Remove as many stones as possible and relieve bile duct strictures. 2. Perform a biliary-enteric drainage procedure based on correcting bile duct strictures and relieving obstructions to widen the bile outflow tract. 3. If the lesion is confined to the left hepatic lobe, a lobectomy may be performed to eradicate the lesion. **Surgical methods:** High bile duct incision and stone removal are generally adopted. Ideally, the common bile duct incision should extend to the hepatic duct confluence, allowing direct visualization to thoroughly clear stones from the branches via the left and right hepatic duct openings, while also incising the narrowed intrahepatic bile ducts. For stones located in superficial areas of the liver, the intrahepatic bile ducts are incised through the liver parenchyma to remove the stones, followed by T-tube placement or biliary-enteric drainage. Biliary-enteric drainage commonly involves Roux-Y hepaticojejunostomy (using the hepatic duct, common hepatic duct, or common bile duct) or interposed jejunal choledochoduodenostomy. In recent years, many surgeons have modified the procedure by creating a subcutaneous blind loop at one end of the jejunal limb for postoperative choledochoscopy or repeat stone removal. Sphincteroplasty and choledochoduodenostomy are less frequently used today for intrahepatic bile duct stones due to the high incidence of severe retrograde infections postoperatively. For unresectable strictures in second-order or higher branches of the right hepatic duct, dilation can be performed through the bile duct incision, followed by placement of a long-arm T-tube or U-tube for support and drainage. Such drainage tubes generally need to remain in place for over a year. Hepatic lobectomy to remove intrahepatic lesions mainly refers to left lobectomy, with left lateral segmentectomy being the most common procedure. Further stone removal is performed via the intrahepatic bile ducts at the liver resection margin, followed by Roux-Y hepaticojejunostomy (Longmire procedure). If the right hepatic duct also contains a few stones, combined intra- and extrahepatic biliary-enteric anastomosis may be performed. For right intrahepatic bile duct stones, some advocate right lobectomy, though most consider this approach too traumatic and not advisable. Therefore, for widespread or multiple bilateral intrahepatic stones or right intrahepatic bile duct stones, lobectomy is generally avoided. Instead, efforts are made to remove as many stones as possible, followed by Roux-Y biliary-enteric anastomosis. Regarding postoperative residual intrahepatic bile duct stones, fiberoptic choledochoscopy via the T-tube sinus tract has been increasingly used in recent years, with a success rate exceeding 90%. Six weeks postoperatively, the T-tube is removed, and the choledochoscope is inserted through the sinus tract into the bile duct to retrieve stones under direct vision using a basket. Some reports also describe using laser or shockwave lithotripsy via this route to fragment stones for expulsion. Since most intrahepatic bile duct stones are pigmented calcium stones, T-tube dissolution therapy has limited efficacy. Given the difficulty in achieving complete surgical resolution of intrahepatic bile duct stones, long-term use of cholagogic medications (both Chinese and Western) is essential postoperatively to ensure bile duct patency, promote residual stone expulsion, and reduce recurrence. Many patients still experience varying degrees of bile duct obstruction and infection postoperatively. In such cases, anti-infective and cholagogic medications should be administered, along with measures to improve overall condition. If complete obstruction or severe infection occurs, repeat surgery may be necessary to relieve obstruction, drain the bile ducts, and control infection.