Choledocholithiasis resident survival guide
|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.|
Life Threatening Causes
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
Shown below is an algorithm depicting the management of choledocholithiasis according to the American Society for Gastrointestinal Endoscopy (ASGE) and the American Gastroenterological Association (AGA).
Incidental bile duct stones
❑ On noninvasive imaging for nonbiliary indications
❑ During evaluation of symptomatic cholelithiasis
❑ Intraoperatively during cholecystectomy
|CBD stones discovered|
|CBD stones discovered|
|❑ Preoperative ERCP and |
CBD stone removal, and
❑ Elective cholecystectomy
|❑ Intraoperative CBD exploration |
and stone removal
|❑ Postoperative ERCP and |
CBD stone removal
Shown below is an algorithm depicting the management of symptomatic cholelithiasis and suspected choledocholithiasis according to the American Society for Gastrointestinal Endoscopy (ASGE) and the American Gastroenterological Association (AGA).
Characterize the symptoms:
❑ Acute or intermittent RUQ or epigastric pain
❑ Pale stools
❑ Dark urine
❑ Nausea & vomiting
❑ Altered mental status
❑ History of recurrent symptoms
❑ History of previous gallbladder disease
Diagnostic predictors for the presence of common bile duct stones:
❑ Bilirubin >4 mg/dL
❑ CBD stone on TAUSG
❑ Clinical ascending cholangitis
❑ Bilirubin 1.8-4 mg/dL
❑ Dilated CBD (>6 mm with gallbladder in situ) on TAUSG
❑ Age >55 years
❑ Abnormal LFT other than bilirubin (elevated alkaline phosphatase & GGT)
❑ Clinical biliary pancreatitis
|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|
❑ 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
❑ 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
- For the management of cholangitis, please click here.
- For the management of pancreatitis, please click here.
- 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).
- 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).
- 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.
- Laparoscopic cholecystectomy is contraindicated in untreated coagulopathy, lack of equipment, lack of surgeon expertise, hostile abdomen, advanced cirrhosis/liver failure, and suspected gallbladder cancer.
- 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.
- 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.
- 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.
- 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.