Choledocholithiasis resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vendhan Ramanujam M.B.B.S [2]

Overview

Choledocholithiasis are bile duct stones that can be either asymptomatic, symptomatic without complications or symptomatic with complications of cholangitis or pancreatitis.

Terms Definitions
Choledocholithiasis (bile duct stones) Choledocholithiasis are crystallized pieces of bile containing cholesterol and bilirubin in the bile duct. It usually results from the migration of gallstones from the gallbladder into the biliary tract.
Primary choledocholithiasis Primary choledocholithiasis are biliary tract stones resulting from biliary stasis and not from the migration of gallstones from the gallbladder into the biliary tract.
Asymptomatic choledocholithiasis Asymptomatic choledocholithiasis refers to the presence of stones in the bile duct, that might be detected during imaging studies of the abdomen, in the absence of any symptoms.
Symptomatic and uncomplicated choledocholithiasis Symptomatic and uncomplicated choledocholithiasis refers to the presence of stones in the bile duct that are associated with symptoms in the absence of complications such as acute cholangitis or pancreatitis.
Symptomatic and complicated choledocholithiasis Symptomatic and complicated choledocholithiasis refers to the presence of stones in the bile duct with symptoms and complications such as acute cholangitis or pancreatitis.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Common Causes

Management

Asymptomatic Choledocholithiasis

Shown below is an algorithm depicting the management of choledocholithiasis according to the American Society for Gastrointestinal Endoscopy (ASGE)[1] and the American Gastroenterological Association (AGA).[2]

 
 
 
Incidental bile duct stones
❑ On noninvasive imaging for nonbiliary indications
❑ During evaluation of symptomatic cholelithiasis
❑ Intraoperatively during cholecystectomy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CBD stones discovered
during imaging
 
 
 
CBD stones discovered
during cholecystectomy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Preoperative ERCP and
CBD stone removal, and
❑ Elective cholecystectomy
 
❑ Intraoperative CBD exploration
and stone removal
 
❑ Postoperative ERCP and
CBD stone removal


Symptomatic Choledocholithiasis

Shown below is an algorithm depicting the management of symptomatic cholelithiasis and suspected choledocholithiasis according to the American Society for Gastrointestinal Endoscopy (ASGE)[1] and the American Gastroenterological Association (AGA).[2]

 
 
 
 
 
 
 
 
Characterize the symptoms:
❑ Acute or intermittent RUQ or epigastric pain
❑ Sharp, severe and steady
❑ > 6 hours
❑ Radiation to the right shoulder blade
❑ Radiation to the back
❑ After food intake
Jaundice
❑ Pale stools
❑ Dark urine
Fever
Nausea & vomiting
Diaphoresis
❑ Altered mental status
❑ History of recurrent symptoms
❑ History of previous gallbladder disease
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:
❑ Altered mental status
Fever
Dehydration
Jaundice
Hypotension
Tachycardia
Dyspnea
Hypoxemia
❑ Abdominal tenderness
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order laboratory tests:
CBC
BMP
CRP
❑ Total bilirubin
❑ Direct bilirubin
Albumin
AST
ALT
❑ Alkaline phosphatase
GGT
Amylase
Lipase
Order transabdominal USG (TAUSG)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Diagnostic predictors for the presence of common bile duct stones:[1]
Very strong:
❑ Bilirubin >4 mg/dL
❑ CBD stone on TAUSG
❑ Clinical ascending cholangitis
❑ Fever
❑ Jaundice
❑ RUQ pain

Strong:
❑ Bilirubin 1.8-4 mg/dL
❑ Dilated CBD (>6 mm with gallbladder in situ) on TAUSG
Moderate:
❑ Age >55 years
❑ Abnormal LFT other than bilirubin (elevated alkaline phosphatase & GGT)
❑ Clinical biliary pancreatitis
❑ Severe epigastric pain radiating to the back
❑ Abdominal tenderness
❑ Nausea
❑ Vomiting
❑ Fever
❑ Dyspnea
❑ Tachycardia
❑ Hypotension
❑ Hypoxemia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No predictors
 
 
 
 
 
One strong and/or at least one moderate predictor
 
 
 
 
 
 
 
 
 
Presence of any very strong or both strong predictors
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Low risk choledocholithiasis
 
 
 
 
 
Intermediate risk choledocholithiasis
 
 
 
 
 
 
 
 
 
High risk choledocholithiasis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patient with symptomatic cholelithiasis proven by GBS or biliary sludge seen during TAUSG
 
 
 
Laparoscopic IOC or US
 
 
 
 
 
Preoperative EUS/MRCP
 
 
 
Preoperative ERCP & CBD stone removal
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cholecystectomy
❑ No preoperative EUS/MRCP or intraoperative cholangiography/US/CBD exploration
 
CBD stones present
 
CBD stones absent
 
CBD stones present
 
CBD stones absent
 
If GBS or sludge seen during imaging
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Laparoscopic CBD exploration
or
❑ Post-operative ERCP
 
❑ Laparoscopic cholecystectomy
 
❑ Preoperative EUS or MRCP
 
❑ Laparoscopic cholecystectomy
 
❑ Elective cholecystectomy
 
 
 
 
 
 

ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; BMP: Basic metabolic profile; CBC: Complete blood count; CBD: Common bile duct; CRP: C-reactive protein; ERCP: Endoscopic retrograde cholangiopancreatography; EUS: Endoscopic ultrasound; GBS: Gallbladder stone; GGT: Gamma-glutamyl transpeptidase; IOC: Intraoperative cholangiography; LFT: Liver function tests; MRCP: Magnetic resonance cholangiopancreatography; RUQ: Right Upper Quadrant; Sx: Symptom; US: Ultrasound; W/: With; W/O: Without

Symptomatic and Complicated Choledocholithiasis

Symptomatic and complicated choledocholithiasis refers to the presence of stones in the bile duct with symptoms and complications such as acute cholangitis or pancreatitis.

  • For the management of cholangitis, please click here.
  • For the management of pancreatitis, please click here.

Do's

  • Order serum liver biochemical tests and a transabdominal ultrasound of the right upper quadrant during the initial evaluation of suspected choledocholithiasis. These tests should be used to risk-stratify patients to guide further evaluation and management (Grade B).[3]
  • Consider EUS or MRCP in the diagnostic evaluation of postcholecystectomy patients suspected of having choledocholithiasis when initial laboratory and ultrasonography data are abnormal yet non diagnostic (Grade C).[3]
  • Consider sphincter of Oddi dysfunction as a differential diagnosis if EUS or MRCP did not detect any stones in the bile duct of postcholecystectomy patients suspected of having choledocholithiasis.
  • Laparoscopic cholecystectomy is preferred over open laparoscopy but conversion to open may be necessary and should not be considered a failure in the management.[4]

Dont's

  • Laparoscopic cholecystectomy is contraindicated in untreated coagulopathy, lack of equipment, lack of surgeon expertise, hostile abdomen, advanced cirrhosis/liver failure, and suspected gallbladder cancer.

References

  1. 1.0 1.1 1.2 Maple, JT.; Ben-Menachem, T.; Anderson, MA.; Appalaneni, V.; Banerjee, S.; Cash, BD.; Fisher, L.; Harrison, ME.; Fanelli, RD. (2010). "The role of endoscopy in the evaluation of suspected choledocholithiasis.". Gastrointest Endosc. 71 (1): 1–9. PMID 20105473. doi:10.1016/j.gie.2009.09.041.  Unknown parameter |month= ignored (help)
  2. 2.0 2.1 Carr-Locke, DL. (2006). "Cholelithiasis plus choledocholithiasis: ERCP first, what next?". Gastroenterology. 130 (1): 270–2. PMID 16401489. doi:10.1053/j.gastro.2005.12.010.  Unknown parameter |month= ignored (help)
  3. 3.0 3.1 Guyatt, GH.; Oxman, AD.; Vist, GE.; Kunz, R.; Falck-Ytter, Y.; Alonso-Coello, P.; Schünemann, HJ.; Alderson, P.; Alonso-Coello, P. (2008). "GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.". BMJ. 336 (7650): 924–6. PMID 18436948. doi:10.1136/bmj.39489.470347.AD.  Unknown parameter |month= ignored (help)
  4. Duncan, CB.; Riall, TS. (2012). "Evidence-based current surgical practice: calculous gallbladder disease.". J Gastrointest Surg. 16 (11): 2011–25. PMID 22986769. doi:10.1007/s11605-012-2024-1.  Unknown parameter |month= ignored (help)

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