Choledocholithiasis

Last updated: March 9, 2022

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Choledocholithiasis refers to the presence of gallstones in the common bile duct (CBD). 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.”

References: [1][2]

Epidemiological data refers to the US, unless otherwise specified.

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

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]

See also “Diagnostic workup of acute abdominal pain.”

Although normal LFTs and transabdominal RUQ ultrasound may help rule out choledocholithiasis, they cannot reliably confirm the diagnosis. CBD stones are rarely seen on ultrasound.

Risk stratification [6]

These risk categories help determine the most appropriate confirmatory imaging and can guide disposition.

Predictors of choledocholithiasis [6]
Strength of predictor Parameter
Very strong
Strong
Moderate

Interpretation [6][7]

  • High likelihood of choledocholithiasis (risk > 50%): ≥ 1 very strong predictor OR 2 strong predictors
  • Intermediate likelihood of choledocholithiasis (risk 10–50%): any predictor that does not meet the criteria for high risk
  • Low likelihood of choledocholithiasis (risk < 10%): No predictors

Laboratory studies

Transabdominal RUQ ultrasound [6][12]

If appropriately trained, consider performing a biliary point-of-care ultrasound (POCUS) to rule-in choledocholithiasis by identifying a dilated CBD or a stone in the CBD. If the biliary POCUS is negative, but clinical suspicion remains high, consider additional imaging (e.g., formal ultrasound, EUS, MRCP).

CT abdomen with IV contrast [6][12]

CT is not routinely recommended if there is a strong suspicion for choledocholithiasis, but it may help exclude alternate diagnoses with similar presentations.

  • 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 [15]
    • Calcium-containing stones may be visualized within the CBD (only 15–20 % stones). [16]

Endoscopic retrograde cholangiopancreatography (ERCP)

Magnetic resonance cholangiopancreatography (MRCP)

  • Indications
  • Characteristic findings: similar to ERCP findings [17]
  • Advantages: noninvasive procedure; sensitivity and specificity rates similar to ERCP [17]

Endoscopic ultrasound (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][22]

Intraoperative imaging [7]

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. [23]

Approach [6][7][24]

Disposition

CBD stone removal [7]

ERCP-guided stone extraction

Avoid urgent ERCP (< 48 hours) if there is biliary pancreatitis without cholangitis or persistent choledocholithiasis. [7]

Laparoscopic bile duct exploration (LCBDE; intraoperative stone extraction) [7][30][31]

  • Indications
    • An alternative to ERCP-guided stone extraction when surgical expertise is available [7][31]
    • 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 [31]

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
  • Options: include mechanical and laser lithotripsy

Elective interval cholecystectomy

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

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