choledocholithiasis; biliary stone
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Introduction
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
Diagnostic procedures
- 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]
- dilation of the common bile duct is common, typically > 6 mm in diameter[9]
- 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
- common bile duct stone may occasionally be seen on abdominal ultrasound or abdominal CT[2]
* cholelithiasis on abdominal ultrasound,
* if no stone in common bile duct on ultrasound, dilated common bile duct, total bilirubin > 1.8 mg/dL & no symptoms of ascending cholangitis suggests choledocholithiasis[2][8]
Complications
(may be life-threatening)
Differential diagnosis
- cholangitis: fever, leukocytosis
- acute pancreatitis:
- fever, leukocytosis, increased serum amylase, serum lipase[2]
- acalculous cholecystitis
- typically occurs in critically ill patients
- due to gallbladder ischemia
- ultrasound: pericholecystic fluid, gallbladder distension, pneumatosis without stones[2]
Management
- endoscopy (ERCP) is safer than surgery for complications
- 85-95% successful
- complications 10%
- mortality rate 1%
- use an 8-mm balloon if endoscopic papillary balloon dilation indicated
- preferred method for removing common bile duct stone[2]
- if discovered during cholecystectomy
- immediate common duct exploration, or
- endoscopic retrograde cholangiopancreatography (ERCP) postoperatively
- observation may appropriate if asymptomatic[3]
- 20% of patients sponatenously pass stones from the common bile duct[2]
- laparoscopic bile duct exploration may be associated with shorter length of stay compared with perioperative ERCP[5]
- 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]
- offer laparoscopic cholecystectomy to all patients following biliary pancreatitis[5]
- operate within 2 weeks, preferably during the index admission.
- in patients with biliary pancreatitis & cholangitis or persistent obstruction, perform ERCP with stone extraction within 72 hours of presentation[5]
More general terms
Additional terms
References
- ↑ Stedman's Medical Dictionary 26th ed, Williams & Wilkins, Baltimore, 1995
- ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 Medical Knowledge Self Assessment Program (MKSAP) 11, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2015, 2018, 2021.
Medical Knowledge Self Assessment Program (MKSAP) 20 American College of Physicians, Philadelphia 2025 - ↑ 3.0 3.1 3.2 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: https://pubmed.ncbi.nlm.nih.gov/14685097 - ↑ 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: https://pubmed.ncbi.nlm.nih.gov/20105473
- ↑ 5.0 5.1 5.2 5.3 5.4 5.5 Williams E et al. Updated guideline on the management of common bile duct stones (CBDS). Gut 2017 Jan 25; <PubMed> PMID: https://pubmed.ncbi.nlm.nih.gov/28122906 <Internet> http://gut.bmj.com/content/early/2017/01/25/gutjnl-2016-312317
- ↑ 6.0 6.1 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: https://pubmed.ncbi.nlm.nih.gov/28809384
- ↑ 7.0 7.1 7.2 7.3 Shalkow J Fast Five Quiz: Test Your Knowledge of Gallstones Medscape. June 12, 2018 https://reference.medscape.com/viewarticle/897845
- ↑ 8.0 8.1 8.2 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:http://dx.doi.org/ 10.1016/j.gie.2009.09.041. PMID: https://pubmed.ncbi.nlm.nih.gov/20105473 - ↑ 9.0 9.1 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: https://pubmed.ncbi.nlm.nih.gov/30465770
- ↑ 10.0 10.1 NEJM Knowledge+ Gastroenterology