- Clinical science
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).
Secondary choledocholithiasis (most common): cholelithiasis → passage of gallstones into the common bile duct → common bile duct obstruction → spasm of the biliary tracts
- Risk factor: a history of cholelithiasis
- Primary choledocholithiasis (less common): conditions predisposing to bile stasis → intraductal stone formation
Postcholecystectomy choledocholithiasis 
- Residual choledocholithiasis: CBD stones missed during cholecystectomy; typically becomes symptomatic within 3 years of surgery
- Recurrent choledocholithiasis: CBD stones that developed after cholecystectomy, typically detected after 3 years of surgery
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. 
- RUQ pain
- Nausea, vomiting, anorexia
- Signs of extrahepatic cholestasis (e.g., jaundice, pale stool, dark urine, pruritus) may be present
- Features of complications: See ''Clinical features'' in acute pancreatitis, acute cholecystitis, and acute cholangitis. 
- Initial evaluation: Liver function tests (LFTs) and RUQ ultrasound are the preferred first-line diagnostic tests.
- Determine the need for confirmatory imaging based on predictors of choledocholithiasis.
- See also “Diagnostic workup of acute abdominal pain.”
- Tests to rule out related biliary comorbidities
Initial imaging 
Transabdominal RUQ ultrasound
- Indications: preferred first-line imaging modality in patients presenting with RUQ pain and/or jaundice 
- Dilated common bile duct (CBD): Normal CBD diameter varies according to patient age and whether the gallbladder is intact or has been surgically removed. 
- Intrahepatic biliary dilatation may be seen.
- Visualization of an occluding CBD stone 
- Stone(s) within the gallbladder (see ''RUQ transabdominal ultrasound'' in cholelithiasis). 
- Predictive value: high negative predictive value (∼ 95%) 
CT abdomen with IV contrast
CT is not routinely recommended if there is a strong suspicion for choledocholithiasis.
- Supportive findings
Risk stratification 
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 |
|Strength of predictor||Parameter|
Confirmatory imaging and further management 
Based on the patient's likelihood of choledocholithiasis, the choice of confirmatory imaging modalities differs.
- High likelihood of choledocholithiasis: ERCP
- Intermediate likelihood of choledocholithiasis: MRCP or EUS, based on patient preference, operator expertise, and costs
- Low likelihood of choledocholithiasis: Confirmatory imaging is not routinely required.
- In postcholecystectomy patients, consider MRCP or EUS to evaluate for suspected residual or recurrent choledocholithiasis. 
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%) 
- Contraindication (for urgent ERCP): acute biliary pancreatitis without evidence of cholangitis or biliary obstruction 
- Characteristic findings
Post-ERCP pancreatitis: pancreatic inflammation secondary to ERCP
- Incidence: ∼ 3.5% 
- Diagnostic criteria (all of the following) 
- 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)
- Post-ERCP pancreatitis: pancreatic inflammation secondary to ERCP
- Patients with an intermediate likelihood of choledocholithiasis 
- Suspected postcholecystectomy choledocholithiasis 
- Characteristic findings: similar to ERCP findings 
- Advantages: noninvasive procedure; sensitivity and specificity rates similar to ERCP 
- Indication: : alternative to MRCP in patients with an intermediate likelihood of choledocholithiasis or suspected postcholecystectomy choledocholithiasis 
- Characteristic findings: same as transabdominal ultrasound
- Advantages: highly sensitive and specific 
Intraoperative imaging 
- Intraoperative cholangiography
- Intraoperative ultrasound
- Differential diagnosis of jaundice with dilated biliary duct
- Differential diagnosis of abdominal pain
- See also “Overview of biliary disease.”
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. 
- Provide supportive therapy for patients with acute symptoms
- Identify and manage any complications (e.g., acute pancreatitis, cholangitis, cholecystitis).
- Removal of choledocholithiasis
- Elective cholecystectomy to prevent recurrence
Removal of choledocholithiasis 
- 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. 
- Intraoperative diagnosis
- Lithotripsy may be considered in patients not suited, or unwilling, to undergo endoscopic or surgical stone removal.
ERCP-guided stone extraction
- Confirmed choledocholithiasis 
- Cholangitis 
- Acute biliary pancreatitis with evidence of persistent choledocholithiasis associated with cholangitis 
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 
- Associated acute biliary pancreatitis with cholangitis: within 24 hours of presentation (see “Acute pancreatitis” for further details) 
- ERCP in combination with any of the following:
Laparoscopic bile duct exploration (LBCDE; intraoperative stone extraction) 
- 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 
Prevention of recurrence
- Procedure: laparoscopic cholecystectomy
- Indication: : recommended in all patients with choledocholithiasis
Timing: depends on associated complications
- Uncomplicated choledocholithiasis: within 72 hours of successful ERCP-guided stone clearance 
- Mild biliary pancreatitis: during the same hospital admission 
- Cholangitis: within 6 weeks of successful ERCP-guided stone clearance 
- Acute cholecystitis (see ''Treatment'' in “Acute cholecystitis” for details) 
- Complications: See “Cholecystectomy.”
Gallstone ileus: mechanical bowel obstruction due to obstructive gallstones 
- Pathophysiology: gallbladder perforation or Mirizzi syndrome → biliary-enteric fistula formation (most commonly cholecystoenteric fistula) between the inflamed gallbladder and bowel → gallstones passing down into bowel lumen
- Symptoms depend on the site of obstruction.
- Diagnosis is based on the Rigler triad: imaging findings of small bowel obstruction, gallstone (most commonly in iliac fossa), and pneumobilia.
- Treatment 
- Gallstone pancreatitis
- Acute cholangitis
- Acute cholecystitis
- Biliary stricture
- Pyogenic liver abscess
We list the most important complications. The selection is not exhaustive.