Choledocholithiasis

Background

• Gallstones in the common bile duct may be asymptomatic but may lead to complications such as acute cholangitis or acute pancreatitis.
• Choledocholithiasis is reported in approximately 4% of the general population and in 10%-20% of patients undergoing cholecystectomy.
• Risk factors are the same as those for cholelithiasis in general, including female sex, and obesity. Other risk factors include pregnancy; prolonged fasting; rapid weight loss; a high fat diet; increasing age; ethnicity (persons or Asian, Native American, or Mexican American descent); and family history.

Evaluation

• Consider the diagnosis of choledocholithiasis in patients presenting with the following symptoms and signs:
  • right upper quadrant abdominal, colicky pain, radiating to right shoulder
  • jaundice
  • nausea and vomiting
  • fever or chills
  • pale stools and dark urine
• Patients may also present with:
  • acute pancreatitis
  • acute cholangitis, which is typically characterized by Charcot triad of fever, right upper quadrant pain, and jaundice
• If suspecting choledocholithiasis in a patient with cholelithiasis, obtain serum liver biochemistry with fractionated bilirubin, a complete blood count, and transabdominal ultrasound of the right upper quadrant.
  • Risk stratification of choledocholithiasis is based on serum bilirubin and ultrasound findings.
    • If high risk, assess the common bile duct for stones (Strong recommendation). Consider assessment with preoperative endoscopic retrograde cholangiopancreatography (ERCP); laparoscopic bile duct exploration is an alternative to ERCP when experienced practitioners are available (Weak recommendation).
    • If intermediate risk (such as gallstone pancreatitis, or an elevated liver tunction test other than bilirubin) , continue further assessment with endoscopic ultrasound (particularly if intrahepatic ductal stones are suspected), magnetic resonance cholangiopancreatography (MRCP), or intraoperative cholangiography (IOC) (but not ERCP unless other imaging modalities are not available) (Strong recommendation).
    • If low risk but the patient has symptomatic gallstones in the gallbladder and has no contraindications for surgery, advise cholecystectomy without a further biliary assessment (Strong recommendation).
  • If there is suspicion of choledocholithiasis after cholecystectomy and abnormal laboratory and ultrasound assessments, consider further assessment with endoscopic ultrasound (EUS) or magnetic resonance cholangiopancreatography (MRCP) (Weak recommendation).

Management

• Remove common bile duct (CBD) stones unless clinical circumstances prevent removal (Strong recommendation).
• Common methods for CBD clearance include:
  • endoscopic sphincterotomy (EST) following endoscopic retrograde cholangiopancreatography (ERCP), pre-, intra-, or post-operative (Strong recommendation)
  • endoscopic papillary balloon dilation following ERCP
  • laparoscopic common duct exploration
• Consider open surgery (laparotomy) when less invasive techniques fail or are unavailable(Weak recommendation).
• If choledocholithiasis with severe acute cholangitis is not responsive to medical treatment, perform urgent therapeutic ERCP (Strong recommendation).
  • After common bile duct clearance, consider placement of a plastic biliary stent to ensure adequate drainage (Weak recommendation).
• If choledocholithiasis and symptomatic gallstones are present and there are no contraindications to surgery, cholecystectomy is also recommended (Strong recommendation).
• For patients with choledocholithiasis who have already had a cholecystectomy, consider ERCP with sphincterotomy for clearance as the primary form of treatment (Weak recommendation).