• Clinical science
  • Clinician

Choledocholithiasis

Summary

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.”

Epidemiology

References: [1][2]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

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]

Clinical features

Diagnostics

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

Approach [7][6]

Initial evaluation

Laboratory studies

Initial imaging [6][11]

Transabdominal RUQ ultrasound

  • Indications: preferred first-line imaging modality in patients presenting with RUQ pain and/or jaundice [12][11]
  • 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.

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

Interpretation [6][7]

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

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

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 [7][6]
  • 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)

EUS [7][6][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 [17][6]

Intraoperative imaging [7]

Differential diagnoses

The differential diagnoses listed here are not exhaustive.

Treatment

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

Approach [7][6][23]

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

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

  • 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
  • Complications: See “Cholecystectomy.”

Acute management checklist

Complications

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

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last updated 07/17/2020
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