Choledocholithiasis

Choledocholithiasis refers to the presence of gallstones in the common bile duct. Characteristic clinical features include right upper quadrant pain and signs of extrahepatic cholestasis. Initial diagnostic evaluation includes an ultrasound and routine laboratory studies, and based on the diagnostic likelihood, confirmatory imaging may involve an endoscopic retrograde cholangiopancreatography (ERCP), magnetic resonance cholangiopancreatography (MRCP), or endoscopic ultrasound (EUS). Treatment consists of stone removal (endoscopically or surgically) and preventing recurrence (e.g., via laparoscopic cholecystectomy).

See also “Cholelithiasis”, “Acute cholecystitis”, and “Acute cholangitis.”

• Sex: ♀ > ♂
• Prevalence: ∼ 5–20% of patients who undergo cholecystectomy have choledocholithiasis at the time of surgery
• Peak incidence: > 40 years

References: ^[1][2]

Epidemiological data refers to the US, unless otherwise specified.

• Secondary choledocholithiasis (most common): cholelithiasis → passage of gallstones into the common bile duct → common bile duct obstruction → spasm of the biliary tracts
  • Risk factor: a history of cholelithiasis
• Primary choledocholithiasis (less common): conditions predisposing to bile stasis → intraductal stone formation
  • Risk factors:
    • Cystic fibrosis
    • Prolonged total parenteral nutrition
• Postcholecystectomy choledocholithiasis ^[3][4][5]
  • Residual choledocholithiasis: CBD stones missed during cholecystectomy; typically becomes symptomatic within 3 years of surgery
  • Recurrent choledocholithiasis: CBD stones that developed after cholecystectomy, typically detected after 3 years of surgery
    • Risk factors for recurrent stones: periampullary duodenal diverticulum, dilated CBD, CBD stricture, chronic cholangitis, sickle cell anemia, and rapid weight loss (e.g., after bariatric surgery)

Symptoms of choledocholithiasis (jaundice, RUQ pain, abnormal LFT) in postcholecystectomy patients may be due to recurrent or residual choledocholithiasis but also due to postinterventional biliary strictures or sphincter of Oddi dysfunction. ^[6]

• RUQ pain
  • More severe and prolonged (may last > 6 hours) than in cholelithiasis
  • Postprandial
  • May radiate to the epigastrium, right shoulder, and back (referred pain)
• Nausea, vomiting, anorexia
• Signs of extrahepatic cholestasis (e.g., jaundice, pale stool, dark urine, pruritus) may be present
• Features of complications: See ''Clinical features'' in acute pancreatitis, acute cholecystitis, and acute cholangitis. ^[5]

Evaluation for choledocholithiasis should be performed in all patients with confirmed symptomatic cholelithiasis or in patients presenting with RUQ pain and/or jaundice.

Approach ^[6][7]

• Initial evaluation: Liver function tests (LFTs) and RUQ ultrasound are the preferred first-line diagnostic tests.
• Determine the need for confirmatory imaging based on predictors of choledocholithiasis.
• See also “Diagnostic workup of acute abdominal pain.”

Initial evaluation

Laboratory studies

• LFTs
  • Characteristic findings: evidence of cholestasis, i.e., ↑ ALP, ↑ GGT, ↑ total and ↑ direct bilirubin ^[8][9][10]
  • Predictive value: high negative predictive value (∼ 97%) ^[6]
• Tests to rule out related biliary comorbidities
  • CBC: Leukocytosis is seen in cholecystitis or cholangitis.
  • Amylase, lipase: elevated in biliary pancreatitis
  • See also “Diagnostics” in cholecystitis, cholangitis, and pancreatitis.

Initial imaging ^[6][11]

Transabdominal RUQ ultrasound

• Indications: preferred first-line imaging modality in patients presenting with RUQ pain and/or jaundice ^[11][12]
• Supportive findings
  • Dilated common bile duct (CBD): Normal CBD diameter varies according to patient age and whether the gallbladder is intact or has been surgically removed. ^[6]
    • Gallbladder in situ, age < 50 years: CBD diameter > 6 mm ^[6]
    • Gallbladder in situ, age > 50 years: CBD diameter > 8 mm ^[13]
    • Postcholecystectomy patients: CBD diameter > 10 mm ^[13]
  • Intrahepatic biliary dilatation may be seen.
  • Visualization of an occluding CBD stone ^[6]
  • Stone(s) within the gallbladder (see ''RUQ transabdominal ultrasound'' in cholelithiasis). ^[6]
• Predictive value: high negative predictive value (∼ 95%) ^[6]

CT abdomen with IV contrast

CT is not routinely recommended if there is a strong suspicion for choledocholithiasis.

• Supportive findings
  • Dilated CBD with/without dilation of the intrahepatic biliary tree
  • Target sign: concentric rings formed by a central hypodense stone surrounded by a rim of iso/hyperdense bile ^[14]
  • Calcium-containing stones may be visualized within the CBD (only 15–20 % stones). ^[15]

Risk stratification ^[6]

Neither LFTs; nor transabdominal ultrasound are confirmatory tests for choledocholithiasis. The presence and strength of predictor(s) aid the risk stratification (likelihood estimation) of choledocholithiasis, which determines the choice of confirmatory imaging.

Confirmatory imaging and further management ^[6][7][16]

Based on the patient's likelihood of choledocholithiasis, the choice of confirmatory imaging modalities differs.

• High likelihood of choledocholithiasis: ERCP
• Intermediate likelihood of choledocholithiasis: MRCP or EUS, based on patient preference, operator expertise, and costs
• Low likelihood of choledocholithiasis: Confirmatory imaging is not routinely required.
• In postcholecystectomy patients, consider MRCP or EUS to evaluate for suspected residual or recurrent choledocholithiasis. ^[6]

Preoperative endoscopic retrograde cholangiopancreatography (ERCP)

• Indication: preferred confirmatory imaging for patients with a high likelihood of choledocholithiasis
  • Diagnostic and therapeutic
  • Highly sensitive and specific (∼ 95%) ^[17]
• Contraindication (for urgent ERCP): acute biliary pancreatitis without evidence of cholangitis or biliary obstruction ^[6][7]
• Characteristic findings
  • Smooth-walled, well-defined, intraluminal filling defect(s) within the CBD, which may be dilated ^[18][19]
  • Dilation of the intrahepatic biliary tree
  • Cholelithiasis: mobile filling defect(s) within the gallbladder lumen
• Complications ^[20]
  • Post-ERCP pancreatitis: pancreatic inflammation secondary to ERCP
    • Incidence: ∼ 3.5% ^[20]
    • Diagnostic criteria (all of the following) ^[21]
      • New or worsened postinterventional abdominal pain
      • New or prolonged hospitalization (at least 2 days)
      • Serum amylase > 3 times the upper limit, measured > 24 hours after the intervention
    • Prevention: Consider indomethacin in high-risk patients
  • Perforation, hemorrhage (both have an incidence of ∼ 1%)
  • Infection: cholangitis, acute cholecystitis (uncommon)
  • Bile duct injury resulting in bile duct strictures (uncommon)

Magnetic resonance cholangiopancreatography (MRCP)

• Indications
  • Patients with an intermediate likelihood of choledocholithiasis ^[7]
  • Suspected postcholecystectomy choledocholithiasis ^[6]
• Characteristic findings: similar to ERCP findings ^[17]
• Advantages: noninvasive procedure; sensitivity and specificity rates similar to ERCP ^[17]

EUS ^[6][7][17]

• Indication: : alternative to MRCP in patients with an intermediate likelihood of choledocholithiasis or suspected postcholecystectomy choledocholithiasis ^[6][7]
  • Second-line confirmatory imaging modality if MRCP findings are inconclusive
  • Preferred confirmatory imaging modality in patients with acute biliary pancreatitis and suspected choledocholithiasis ^[7]
• Characteristic findings: same as transabdominal ultrasound
• Advantages: highly sensitive and specific ^[6][17]

• Differential diagnosis of jaundice with dilated biliary duct
  • Biliary stricture
  • Pancreatic carcinoma (head of pancreas)
  • Cholangiocarcinoma
  • Mirizzi syndrome
  • Extrinsic compression of the bile duct (e.g., lymphadenopathy at the porta hepatis)
• Differential diagnosis of abdominal pain
  • See ''RUQ'' in differential diagnoses of acute abdominal pain.
  • See differential diagnoses of abdominal pain.
• See also “Overview of biliary disease.”

The differential diagnoses listed here are not exhaustive.

Treatment is recommended in all patients with choledocholithiasis, even if asymptomatic. The mainstay of treatment is the removal of the obstruction. ^[22]

Approach ^[6][7][23]

• Provide supportive therapy for patients with acute symptoms
  • See initial supportive therapy of acute biliary disease for details on analgesics, spasmolytics, and antiemetics.
  • NPO in patients with acute pain
• Identify and manage any complications (e.g., acute pancreatitis, cholangitis, cholecystitis).
• Removal of choledocholithiasis
• Elective cholecystectomy to prevent recurrence

Removal of choledocholithiasis ^[7]

• Choledocholithiasis may be removed endoscopically (ERCP) or surgically (LCBDE).
  • Intraoperative diagnosis
    • Intraoperative CBD exploration (LCBDE) and stone extraction
    • OR postoperative ERCP-guided stone extraction
  • Preoperative or postoperative diagnosis: ERCP-guided stone extraction is preferred.
  • In patients with postcholecystectomy residual or recurrent choledocholithiasis: ERCP with papillotomy is preferred. ^[4][24]
• Lithotripsy may be considered in patients not suited, or unwilling, to undergo endoscopic or surgical stone removal.

ERCP-guided stone extraction

• Indications
  • Confirmed choledocholithiasis ^[7]
  • Cholangitis ^[25]
  • Acute biliary pancreatitis with evidence of persistent choledocholithiasis associated with cholangitis ^[7][26]
• Timing: depends on whether there are complications and the timing of diagnosis
  • Uncomplicated choledocholithiasis: preoperatively or postoperatively, depending on when the diagnosis was confirmed in relation to cholecystectomy
  • Associated cholecystitis: same as that for uncomplicated choledocholithiasis
  • Associated cholangitis: depends on the severity of cholangitis as well as operative and anesthesia risks ^[27][28]
    • Mild/moderate acute cholangitis in low-risk patients: within 24–48 hours of presentation
    • Moderate/severe acute cholangitis or high-risk patients: after resolution of acute symptoms (i.e, after urgent biliary drainage)
    • See “Cholangitis” for further details.
  • Associated acute biliary pancreatitis with cholangitis: within 24 hours of presentation (see “Acute pancreatitis” for further details) ^[26]
• Procedure
  • ERCP in combination with any of the following:
    • Papillotomy (sphincterotomy): the sphincter of Oddi is incised using a cautery → widening of the lumen of the distal CBD → facilitation of stone extraction with a basket or balloon ^[29]
    • Papillary balloon dilation
    • Sphincterotomy and papillary balloon dilation
    • CBD stenting

Laparoscopic bile duct exploration (LBCDE; intraoperative stone extraction) ^[7][29][30]

• Indications
  • An alternative to ERCP-guided stone extraction when surgical expertise is available ^[7][30]
  • Stones not suited to extraction
  • Patients with altered GIT anatomy (e.g., status post-Roux-en-Y surgery) for whom ERCP-guided stone extraction is not feasible
• Procedure: incision is made either on the cystic duct (transcystic approach) or CBD directly (choledochotomy approach) and the stone is either flushed out or manually extracted ^[30]

Lithotripsy ^[7]

• Indications
  • Large choledocholithiasis not suited to extraction via ERCP or surgery
  • Complex bile duct anatomy (e.g., distal CBD stricture) that makes ERCP and LCBDE challenging
  • Persistent choledocholithiasis despite ERCP and LCBDE is not possible

Prevention of recurrence

• Procedure: laparoscopic cholecystectomy
• Indication: : recommended in all patients with choledocholithiasis
• Timing: depends on associated complications
  • Uncomplicated choledocholithiasis: within 72 hours of successful ERCP-guided stone clearance ^[23][31]
  • Mild biliary pancreatitis: during the same hospital admission ^[7][26][32]
  • Cholangitis: within 6 weeks of successful ERCP-guided stone clearance ^[25]
  • Acute cholecystitis (see ''Treatment'' in “Acute cholecystitis” for details) ^[33][34]
    • Early laparoscopic cholecystectomy: patients with low operative and anesthesia risks
    • Delayed laparoscopic cholecystectomy: patients with high operative and anesthesia risks at initial presentation
• Complications: See “Cholecystectomy.”

• NPO
• Consult GI for urgent ERCP and stone removal.
• Consult surgery for same-admission cholecystectomy (and potential laparoscopic bile duct exploration).
• Identify and treat any complications (see “Cholangitis” and “Acute Cholecystitis”)
• Supportive care: See ”Initial supportive therapy of acute biliary disease”.
• IV fluid therapy

• Gallstone ileus: mechanical bowel obstruction due to obstructive gallstones ^[35][36]
  • Pathophysiology: gallbladder perforation or Mirizzi syndrome → biliary-enteric fistula formation (most commonly cholecystoenteric fistula) between the inflamed gallbladder and bowel → gallstones passing down into bowel lumen
    • Sites of obstruction
      • Terminal ileum, at ileocecal valve (most common)
      • Gastric pylorus or duodenum ^[37]
  • Symptoms depend on the site of obstruction.
    • Distal bowel obstruction: features of mechanical bowel obstruction (abdominal pain and distention, nausea, vomiting)
    • Gastroduodenal obstruction (rare): features of gastric outlet obstruction (Bouveret syndrome) ^[37]
  • Diagnosis is based on the Rigler triad: imaging findings of small bowel obstruction, gallstone (most commonly in iliac fossa), and pneumobilia.
  • Treatment ^[35]
    • Initial supportive therapy
      • NPO, IV fluid resuscitation, analgesics, antiemetics, nasogastric tube insertion
      • Empiric antibiotic therapy for intra-abdominal infections
    • Enterolithotomy: emergency surgery to remove the obstructing stone
    • Consider cholecystectomy and closure of the biliary-enteric fistula. ^[35]
• Gallstone pancreatitis
• Acute cholangitis
• Acute cholecystitis
• Biliary stricture
• Pyogenic liver abscess

We list the most important complications. The selection is not exhaustive.