• Clinical science
  • Clinician



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.”


References: [1][2]

Epidemiological data refers to the US, unless otherwise specified.


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


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

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 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


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

  • 1. Stinton LM, Shaffer EA. Epidemiology of gallbladder disease: cholelithiasis and cancer. Gut Liver. 2012; 6(2): pp. 172–187. doi: 10.5009/gnl.2012.6.2.172.
  • 2. Chandrasekhara V, Elmunzer BJ, Khashab M, Muthusamy M. Clinical Gastrointestinal Endoscopy. Elsevier; 2018.
  • 3. Ahmed M, Spataro J, Tolaymat M, et al. Prevalence and risk factors for choledocholithiasis after cholecystectomy. American Journal of Gastroenetrology. 2017. url: https://journals.lww.com/ajg/Fulltext/2017/10001/Prevalence_and_Risk_Factors_for.72.aspx.
  • 4. 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: pp. 1–6. doi: 10.1155/2012/417821.
  • 5. Ahmed M, Spataro J, Tolaymat M, et al. Complicated choledocholithiasis more common after cholecystectomy. EC Gastroenterology and Digestive System. 2018. url: https://www.ecronicon.com/ecgds/pdf/ECGDS-05-00301.pdf.
  • 6. Maple JT, Ben-Menachem T, Anderson MA, et al. The role of endoscopy in the evaluation of suspected choledocholithiasis. Gastrointest Endosc. 2010; 71(1): pp. 1–9. doi: 10.1016/j.gie.2009.09.041.
  • 7. 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): pp. 1075–1105.e15. doi: 10.1016/j.gie.2018.10.001.
  • 8. 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): pp. 1522–5. pmid: 11148992.
  • 9. Kelly NM, Tham T. Abnormal Liver Function Tests in Acute Cholecystitis With and Without Choledocholithiasis. Gastroenterology. 2011; 140(5): pp. S–450. doi: 10.1016/s0016-5085(11)61847-7.
  • 10. 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): pp. 1241–7. doi: 10.1002/bjs.4955.
  • 11. Hindman NM, Arif-Tiwari H, Kamel RI, et al. American College of Radiology ACR Appropriateness Criteria® Jaundice. https://acsearch.acr.org/docs/69497/Narrative/. Updated January 1, 2018. Accessed May 26, 2020.
  • 12. Peterson CM, McNamara MM, et al. American College of Radiology ACR Appropriateness Criteria® Right Upper Quadrant Pain. https://acsearch.acr.org/docs/69474/Narrative/. Updated January 1, 2018. Accessed August 28, 2019.
  • 13. 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): pp. 39–42. doi: 10.1016/j.ejrad.2010.11.007.
  • 14. 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): pp. 125–130. doi: 10.2214/ajr.181.1.1810125.
  • 15. 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): pp. 226–31. pmid: 25866583.
  • 16. Lee TY. Optimal Evaluation of Suspected Choledocholithiasis: Does This Patient Really Have Choledocholithiasis?. Clinical endoscopy. 2017; 50(5): pp. 415–416. doi: 10.5946/ce.2017.146.
  • 17. Feldman M, Friedman LS, Brandt LJ. Sleisenger and Fordtran's Gastrointestinal and Liver Disease- 2 Volume Set. Elsevier; 2020.
  • 18. Sahani DV, Samir AE. Abdominal Imaging. Elsevier Health Sciences; 2016.
  • 19. Harisinghani MM, Chen JW, Weissleder R. Primer of Diagnostic Imaging. Elsevier; 2018.
  • 20. Anderson MA, Fisher L, Jain R, et al. Complications of ERCP. Gastrointest Endosc. 2012; 75(3): pp. 467–473. doi: 10.1016/j.gie.2011.07.010.
  • 21. Thaker AM, Mosko JD, Berzin TM. Post-endoscopic retrograde cholangiopancreatography pancreatitis. Gastroenterology report. 2015; 3(1): pp. 32–40. doi: 10.1093/gastro/gou083.
  • 22. Tazuma S, Unno M, Igarashi Y, et al. Evidence-based clinical practice guidelines for cholelithiasis 2016. J Gastroenterol. 2016; 52(3): pp. 276–300. doi: 10.1007/s00535-016-1289-7.
  • 23. 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): pp. 146–181. doi: 10.1016/j.jhep.2016.03.005.
  • 24. 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): pp. 118–124. doi: 10.1016/s1230-8013(11)70030-3.
  • 25. 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): pp. 483–488. doi: 10.1016/j.amjsurg.2009.11.010.
  • 26. Tenner S, Baillie J, Dewitt J, Vege SS. American College of Gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol. 2013; 108(9): pp. 1400–1415. doi: 10.1038/ajg.2013.218.
  • 27. 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): pp. 17–30. doi: 10.1002/jhbp.512.
  • 28. 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): pp. 31–40. doi: 10.1002/jhbp.509.
  • 29. Molvar C, Glaenzer B. Choledocholithiasis: Evaluation, Treatment, and Outcomes. Seminars in interventional radiology. 2016; 33(4): pp. 268–276. doi: 10.1055/s-0036-1592329.
  • 30. Memon MA, Hassaballa H, Memon MI. Laparoscopic common bile duct exploration: the past, the present, and the future. Am J Surg. 2000; 179(4): pp. 309–15. doi: 10.1016/s0002-9610(00)00346-9.
  • 31. Huang RJ, Barakat MT, Girotra M, Banerjee S. Practice Patterns for Cholecystectomy After Endoscopic Retrograde Cholangiopancreatography for Patients With Choledocholithiasis. Gastroenterology. 2017; 153(3): pp. 762–771.e2. doi: 10.1053/j.gastro.2017.05.048.
  • 32. Crockett et al. American Gastroenterological Association Institute Guideline on Initial Management of Acute Pancreatitis. Gastroenterology. 2018; 154(4): pp. 1096–1101. doi: 10.1053/j.gastro.2018.01.032.
  • 33. 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.
  • 34. Gutt CN, Encke J, Köninger J, et al. Acute Cholecystitis. Ann Surg. 2013; 258(3): pp. 385–393. doi: 10.1097/sla.0b013e3182a1599b.
  • 35. 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.
  • 36. Abich E, Glotzer D, Murphy E. Gallstone Ileus: An Unlikely Cause of Mechanical Small Bowel Obstruction. Case Reports in Gastroenterology. 2017; 11(2): pp. 389–395. doi: 10.1159/000475749.
  • 37. Caldwell KM, Lee SJ, Leggett PL, Bajwa KS, Mehta SS, Shah SK. Bouveret syndrome: current management strategies. Clinical and experimental gastroenterology. 2018; 11: pp. 69–75. doi: 10.2147/CEG.S132069.
  • Gurusamy KS, Giljaca V, Takwoingi Y, et al. Endoscopic retrograde cholangiopancreatography versus intraoperative cholangiography for diagnosis of common bile duct stones. Cochrane Database of Systematic Reviews. 2015. doi: 10.1002/14651858.cd010339.pub2.
  • Heuman DM. Gallstones (Cholelithiasis). In: Gallstones (Cholelithiasis). New York, NY: WebMD. http://emedicine.medscape.com/article/175667-treatment. Updated April 14, 2016. Accessed February 14, 2017.
  • 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.
  • 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): pp. 472–491. doi: 10.1055/a-0862-0346.
  • VanderVelde J, Goldberg RF. Clinical Algorithms in General Surgery. Springer, Cham; 2019.
  • Afdhal NH. Epidemiology of and risk factors for gallstones. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/epidemiology-of-and-risk-factors-for-gallstones. Last updated November 28, 2016. Accessed March 1, 2017.
  • Arain MA, Freeman ML. Choledocholithiasis: Clinical manifestations, diagnosis, and management. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/choledocholithiasis-clinical-manifestations-diagnosis-and-management. Last updated March 13, 2015. Accessed February 14, 2017.
last updated 10/16/2020
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