Last updated: November 3, 2023

Summarytoggle arrow icon

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.”

Epidemiologytoggle arrow icon

References: [1][2]

Epidemiological data refers to the US, unless otherwise specified.

Etiologytoggle arrow icon

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]

Clinical featurestoggle arrow icon

Diagnosticstoggle arrow icon

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

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)

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]

Differential diagnosestoggle arrow icon

The differential diagnoses listed here are not exhaustive.

Treatmenttoggle arrow icon

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]


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

Acute management checklisttoggle arrow icon

Complicationstoggle arrow icon

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

Referencestoggle arrow icon

  1. Ahmed M, Spataro J, Tolaymat M, et al. Complicated choledocholithiasis more common after cholecystectomy. EC Gastroenterology and Digestive System. 2018.
  2. Buxbaum JL, Abbas Fehmi SM, Sultan S, et al. ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis. Gastrointest Endosc. 2019; 89 (6): p.1075-1105.e15.doi: 10.1016/j.gie.2018.10.001 . | Open in Read by QxMD
  3. Maple JT, Ben-Menachem T, Anderson MA, et al. The role of endoscopy in the evaluation of suspected choledocholithiasis. Gastrointest Endosc. 2010; 71 (1): p.1-9.doi: 10.1016/j.gie.2009.09.041 . | Open in Read by QxMD
  4. Lee TY. Optimal Evaluation of Suspected Choledocholithiasis: Does This Patient Really Have Choledocholithiasis?. Clinical endoscopy. 2017; 50 (5): p.415-416.doi: 10.5946/ce.2017.146 . | Open in Read by QxMD
  5. Pereira-Limâ JC, Jakobs R, Busnello JV, Benz C, Blaya C, Riemann JF. The role of serum liver enzymes in the diagnosis of choledocholithiasis.. Hepatogastroenterology. 2000; 47 (36): p.1522-5.
  6. Kelly NM, Tham T. Abnormal Liver Function Tests in Acute Cholecystitis With and Without Choledocholithiasis. Gastroenterology. 2011; 140 (5): p.S-450.doi: 10.1016/s0016-5085(11)61847-7 . | Open in Read by QxMD
  7. Peng WK, Sheikh Z, Paterson-Brown S, Nixon SJ. Role of liver function tests in predicting common bile duct stones in acute calculous cholecystitis.. Br J Surg. 2005; 92 (10): p.1241-7.doi: 10.1002/bjs.4955 . | Open in Read by QxMD
  8. American College of Radiology ACR Appropriateness Criteria® Jaundice. Updated: January 1, 2018. Accessed: May 26, 2020.
  9. American College of Radiology ACR Appropriateness Criteria® Right Upper Quadrant Pain. Updated: January 1, 2018. Accessed: August 28, 2019.
  10. Senturk S, Miroglu TC, Bilici A, et al. Diameters of the common bile duct in adults and postcholecystectomy patients: a study with 64-slice CT.. Eur J Radiol. 2012; 81 (1): p.39-42.doi: 10.1016/j.ejrad.2010.11.007 . | Open in Read by QxMD
  11. Petrescu I, Bratu AM, Petrescu S, Popa BV, Cristian D, Burcos T. CT vs. MRCP in choledocholithiasis jaundice.. Journal of medicine and life. 2015; 8 (2): p.226-31.
  12. Feldman M, Friedman LS, Brandt LJ. Sleisenger and Fordtran's Gastrointestinal and Liver Disease- 2 Volume Set. Elsevier ; 2020
  13. Miller FH, Hwang CM, Gabriel H, Goodhartz LA, Omar AJ, Parsons WG. Contrast-Enhanced Helical CT of Choledocholithiasis. American Journal of Roentgenology. 2003; 181 (1): p.125-130.doi: 10.2214/ajr.181.1.1810125 . | Open in Read by QxMD
  14. Sahani DV, Samir AE. Abdominal Imaging. Elsevier Health Sciences ; 2016
  15. Harisinghani MM, Chen JW, Weissleder R. Primer of Diagnostic Imaging. Elsevier ; 2018
  16. Anderson MA, Fisher L, Jain R, et al. Complications of ERCP. Gastrointest Endosc. 2012; 75 (3): p.467-473.doi: 10.1016/j.gie.2011.07.010 . | Open in Read by QxMD
  17. Thaker AM, Mosko JD, Berzin TM. Post-endoscopic retrograde cholangiopancreatography pancreatitis.. Gastroenterology report. 2015; 3 (1): p.32-40.doi: 10.1093/gastro/gou083 . | Open in Read by QxMD
  18. Sugiyama M, Atomi Y. Endoscopic ultrasonography for diagnosing choledocholithiasis: a prospective comparative study with ultrasonography and computed tomography. Gastrointest Endosc. 1997; 45 (2): p.143-146.doi: 10.1016/s0016-5107(97)70237-2 . | Open in Read by QxMD
  19. Tazuma S, Unno M, Igarashi Y, et al. Evidence-based clinical practice guidelines for cholelithiasis 2016. J Gastroenterol. 2016; 52 (3): p.276-300.doi: 10.1007/s00535-016-1289-7 . | Open in Read by QxMD
  20. European Association for the Study of the Liver (EASL). EASL Clinical Practice Guidelines on the prevention, diagnosis and treatment of gallstones.. J Hepatol. 2016; 65 (1): p.146-181.doi: 10.1016/j.jhep.2016.03.005 . | Open in Read by QxMD
  21. Oak JH, Paik CN, Chung WC, Lee K-M, Yang JM. Risk Factors for Recurrence of Symptomatic Common Bile Duct Stones after Cholecystectomy. Gastroenterology Research and Practice. 2012; 2012: p.1-6.doi: 10.1155/2012/417821 . | Open in Read by QxMD
  22. Komarowska M, Snarska J, Troska P, Suszkiewicz R. Recurrent residual choledocholithiasis after cholecystectomy – endoscopic exploration of bile ducts performed 6 times. Polish Annals of Medicine. 2011; 18 (1): p.118-124.doi: 10.1016/s1230-8013(11)70030-3 . | Open in Read by QxMD
  23. Li VK, Yum JL, Yeung YP. Optimal timing of elective laparoscopic cholecystectomy after acute cholangitis and subsequent clearance of choledocholithiasis. Am J Surg. 2010; 200 (4): p.483-488.doi: 10.1016/j.amjsurg.2009.11.010 . | Open in Read by QxMD
  24. Kiriyama S, Kozaka K, Takada T, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholangitis (with videos). Journal of Hepato-Biliary-Pancreatic Sciences. 2018; 25 (1): p.17-30.doi: 10.1002/jhbp.512 . | Open in Read by QxMD
  25. Miura F, Okamoto K, Takada T, et al. Tokyo Guidelines 2018: initial management of acute biliary infection and flowchart for acute cholangitis. Journal of Hepato-Biliary-Pancreatic Sciences. 2018; 25 (1): p.31-40.doi: 10.1002/jhbp.509 . | Open in Read by QxMD
  26. Tenner S, Baillie J, Dewitt J, Vege SS. American College of Gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol. 2013; 108 (9): p.1400-1415.doi: 10.1038/ajg.2013.218 . | Open in Read by QxMD
  27. Molvar C, Glaenzer B. Choledocholithiasis: Evaluation, Treatment, and Outcomes.. Seminars in interventional radiology. 2016; 33 (4): p.268-276.doi: 10.1055/s-0036-1592329 . | Open in Read by QxMD
  28. Memon MA, Hassaballa H, Memon MI. Laparoscopic common bile duct exploration: the past, the present, and the future.. Am J Surg. 2000; 179 (4): p.309-15.doi: 10.1016/s0002-9610(00)00346-9 . | Open in Read by QxMD
  29. Huang RJ, Barakat MT, Girotra M, Banerjee S. Practice Patterns for Cholecystectomy After Endoscopic Retrograde Cholangiopancreatography for Patients With Choledocholithiasis. Gastroenterology. 2017; 153 (3): p.762-771.e2.doi: 10.1053/j.gastro.2017.05.048 . | Open in Read by QxMD
  30. Crockett et al. American Gastroenterological Association Institute Guideline on Initial Management of Acute Pancreatitis. Gastroenterology. 2018; 154 (4): p.1096-1101.doi: 10.1053/j.gastro.2018.01.032 . | Open in Read by QxMD
  31. Schuster KM, Holena DN, Salim A, Savage S, Crandall M. American Association for the Surgery of Trauma emergency general surgery guideline summaries 2018: acute appendicitis, acute cholecystitis, acute diverticulitis, acute pancreatitis, and small bowel obstruction.. Trauma surgery & acute care open. 2019; 4 (1): p.e000281.doi: 10.1136/tsaco-2018-000281 . | Open in Read by QxMD
  32. Gutt CN, Encke J, Köninger J, et al. Acute Cholecystitis. Ann Surg. 2013; 258 (3): p.385-393.doi: 10.1097/sla.0b013e3182a1599b . | Open in Read by QxMD
  33. Nuño-Guzmán CM, Marín-Contreras ME, Figueroa-Sánchez M, Corona JL. Gallstone ileus, clinical presentation, diagnostic and treatment approach. World J Gastrointest Surg. 2016; 8 (1): p.65.doi: 10.4240/wjgs.v8.i1.65 . | Open in Read by QxMD
  34. Abich E, Glotzer D, Murphy E. Gallstone Ileus: An Unlikely Cause of Mechanical Small Bowel Obstruction. Case Reports in Gastroenterology. 2017; 11 (2): p.389-395.doi: 10.1159/000475749 . | Open in Read by QxMD
  35. Caldwell KM, Lee SJ, Leggett PL, Bajwa KS, Mehta SS, Shah SK. Bouveret syndrome: current management strategies.. Clinical and experimental gastroenterology. 2018; 11: p.69-75.doi: 10.2147/CEG.S132069 . | Open in Read by QxMD
  36. Stinton LM, Shaffer EA. Epidemiology of gallbladder disease: cholelithiasis and cancer. Gut Liver. 2012; 6 (2): p.172-187.doi: 10.5009/gnl.2012.6.2.172 . | Open in Read by QxMD
  37. Chandrasekhara V, Elmunzer BJ, Khashab M, Muthusamy M. Clinical Gastrointestinal Endoscopy. Elsevier ; 2018
  38. Ahmed M, Spataro J, Tolaymat M, et al. Prevalence and risk factors for choledocholithiasis after cholecystectomy. American Journal of Gastroenetrology. 2017.
  39. Arain MA, Freeman ML. Choledocholithiasis: Clinical manifestations, diagnosis, and management. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. Last updated: March 13, 2015. Accessed: February 14, 2017.
  40. Heuman DM. Gallstones (Cholelithiasis). Gallstones (Cholelithiasis). New York, NY: WebMD. Updated: April 14, 2016. Accessed: February 14, 2017.
  41. Afdhal NH. Epidemiology of and risk factors for gallstones. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. Last updated: November 28, 2016. Accessed: March 1, 2017.
  42. Gurusamy KS, Giljaca V, Takwoingi Y, et al. Ultrasound versus liver function tests for diagnosis of common bile duct stones.. The Cochrane database of systematic reviews. 2015: p.CD011548.doi: 10.1002/14651858.CD011548 . | Open in Read by QxMD
  43. Manes G, Paspatis G, Aabakken L, et al. Endoscopic management of common bile duct stones: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy. 2019; 51 (05): p.472-491.doi: 10.1055/a-0862-0346 . | Open in Read by QxMD

Icon of a lock3 free articles remaining

You have 3 free member-only articles left this month. Sign up and get unlimited access.
 Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer