Contents

Search

choledocholithiasis; biliary stone

The presence of a gallstone in the common bile duct. Etiology: - 20% of patients with cholecystitis Pathology: - dilation of the common bile duct is common, typically > 6 mm in diameter - commonly, stones impact distally in the ampulla of Vater [7] Clinical manifestations: - may be asymptomatic [3] - < 50% of patients develop symptoms [2] - may cause obstructive jaundice - biliary colic indistinguishable from that caused by cystic duct stones [7] - right upper quadrant pain or epigastric pain - pain may radiate to the back or right shoulder - episodes of pain lasting 30 minutes to 3 hours [2] - nausea/vomiting may occur - also see cholecystitis, cholangitis & acute pancreatitis Laboratory: - liver function tests - elevated serum aspartate aminotransferase (serum AST) - elevated serum alanine aminotransferase (serum ALT) - elevated serum bilirubin* - elevated serum alkaline phosphatase* * serum bilirubin & serum alkaline phosphatase increased more so than serum ALT & serum AST Special laboratory: - initial evaluation: right upper quadrant ultrasound - dilation of the common bile duct is common, typically > 6 mm in diameter [9] - may be absent if obstruction of recent onset [7] - endoscopic ultrasound (pre-op, intermediate probability) - endoscopic retrograde cholangiopancreatography (ERCP) - high probability/risk)* with sphincterotomy using propofol or general anesthesia [5] - preferred method for removing common bile duct stone [2] * clinical criteria for high risk - visualization of stone within common bile duct on RUQ ultrasound - clinical evidence of ascending cholangitis (fever, leukocytosis) - serum bilirubin (total) > 4 mg/dL - common bile duct diameter > 6 mm with an intact gallbladder & serum bilirubin (total) of 1.8 - 4.0 mg/dL [10] Radiology: - magnetic resonance cholangiography vs endoscopic ultrasound - intermediate risk* choledocholithiasis (ERCP for high risk) [8] - common bile duct stone may occasionally be seen on abdominal ultrasound or abdominal CT [2] * cholelithiasis on abdominal ultrasound, dilated common bile duct, total bilirubin > 1.8 mg/dL, no stone in common bile duct on ultrasound, no symptoms of ascending cholangitis [8] Complications: (may be life-threatening) 1) cholangitis 2) acute pancreatitis Differential diagnosis: 1) cholangitis: fever, leukocytosis 2) acute pancreatitis: - fever, leukocytosis, increased serum amylase, serum lipase [2] Management: 1) endoscopy (ERCP) is safer than surgery for complications a) 85-95% successful b) complications 10% c) mortality rate 1% d) use an 8-mm balloon if endoscopic papillary balloon dilation indicated e) preferred method for removing common bile duct stone [2] 2) if discovered during cholecystectomy a) immediate common duct exploration, or b) endoscopic retrograde cholangiopancreatography (ERCP) postoperatively 3) observation may appropriate if asymptomatic [3] 4) 20% of patients sponatenously pass stones from the common bile duct [2] 5) laparoscopic bile duct exploration may be associated with shorter length of stay compared with perioperative ERCP [5] 6) cholecystectomy unless surgery risk is too high [5] - consider biliary sphincterotomy & stone extraction or biliary stent as alternative. - laparoscopic cholecystectomy after ERCP with sphincterotomy [6] 7) offer laparoscopic cholecystectomy to all patients following biliary pancreatitis [5] - operate within 2 weeks, preferably during the index admission. 8) in patients with biliary pancreatitis & cholangitis or persistent obstruction, perform ERCP with stone extraction within 72 hours of presentation [5]

Related

acute pancreatitis cholangitis

General

cholelithiasis (gallstones)

References

  1. Stedman's Medical Dictionary 26th ed, Williams & Wilkins, Baltimore, 1995
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2015, 2018, 2021.
  3. Journal Watch 24(4):31, 2004 - Collins C et al A prospective study of common bile duct calculi in patients undergoing laparoscopic cholecystectomy: natural history of choledocholithiasis revisited. Ann Surg 239:28, 2004 PMID: 14685097
  4. ASGE Standards of Practice Committee, Maple JT, Ben-Menachem T, Anderson MA et al The role of endoscopy in the evaluation of suspected choledocholithiasis. Gastrointest Endosc. 2010 Jan;71(1):1-9 PMID: 20105473
  5. Williams E et al. Updated guideline on the management of common bile duct stones (CBDS). Gut 2017 Jan 25; PMID: 28122906 http://gut.bmj.com/content/early/2017/01/25/gutjnl-2016-312317
  6. Elmunzer BJ, Noureldin M, Morgan KA et al. The impact of cholecystectomy after endoscopic sphincterotomy for complicated gallstone disease. Am J Gastroenterol 2017 Aug 15; PMID: 28809384
  7. Shalkow J Fast Five Quiz: Test Your Knowledge of Gallstones Medscape. June 12, 2018 https://reference.medscape.com/viewarticle/897845
  8. NEJM Knowledge+ Question of the Week. Feb 12, 2019 https://knowledgeplus.nejm.org/question-of-week/1668/ - ASGE Standards of Practice Committee, Maple JT et al The role of endoscopy in the evaluation of suspected choledocholithiasis. Gastrointest Endosc. 2010 Jan;71(1):1-9. doi: 10.1016/j.gie.2009.09.041. PMID: 20105473
  9. Chisholm PR, Patel AH, Law RJ et al Preoperative predictors of choledocholithiasis in patients presenting with acute calculous cholecystitis. Gastrointest Endosc. 2019 May;89(5):977-983.e2. PMID: 30465770
  10. NEJM Knowledge+ Gastroenterology