Choledocholithiasis resident survival guide: Difference between revisions

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{{CMG}}; {{AE}} {{VR}}
{{CMG}}; {{AE}} {{VR}}


==Definitions==
==Overview==
 
[[Choledocholithiasis]] are bile duct stones that can be either asymptomatic, symptomatic without complications or symptomatic with complications of [[cholangitis]] or [[pancreatitis]].
 
{|class="wikitable"
{|class="wikitable"
! Terms!! Definitions
! Terms!! Definitions
|-
|-
| Choledocholithiasis (bile duct stones)|| Choledocholithiasis are crystallized pieces of [[bile]] including cholesterol and bilirubin in the bile duct.  It usually refers to the [[gallstones]] that have migrated into the biliary tract from the [[gallbladder]].
| '''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.
| '''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.
| '''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 [[Cholangitis|acute cholangitis]] or [[pancreatitis]].
| '''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 [[Cholangitis|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]].
| '''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]].
|-
|-
|}
|}
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==Management==
==Management==
Shown below is a diagram depicting the management of choledocholithiasis according to American Society for Gastrointestinal Endoscopy (ASGE)<ref name="Maple-2010">{{Cite journal  | last1 = Maple | first1 = JT. | last2 = Ben-Menachem | first2 = T. | last3 = Anderson | first3 = MA. | last4 = Appalaneni | first4 = V. | last5 = Banerjee | first5 = S. | last6 = Cash | first6 = BD. | last7 = Fisher | first7 = L. | last8 = Harrison | first8 = ME. | last9 = Fanelli | first9 = RD. | title = The role of endoscopy in the evaluation of suspected choledocholithiasis. | journal = Gastrointest Endosc | volume = 71 | issue = 1 | pages = 1-9 | month = Jan | year = 2010 | doi = 10.1016/j.gie.2009.09.041 | PMID = 20105473 }}</ref> and American Gastroenterological Association (AGA).<ref name="Carr-Locke-2006">{{Cite journal  | last1 = Carr-Locke | first1 = DL. | title = Cholelithiasis plus choledocholithiasis: ERCP first, what next? | journal = Gastroenterology | volume = 130 | issue = 1 | pages = 270-2 | month = Jan | year = 2006 | doi = 10.1053/j.gastro.2005.12.010 | PMID = 16401489 }}</ref>
===Asymptomatic Choledocholithiasis===
Shown below is an algorithm depicting the management of choledocholithiasis according to the American Society for Gastrointestinal Endoscopy (ASGE)<ref name="Maple-2010">{{Cite journal  | last1 = Maple | first1 = JT. | last2 = Ben-Menachem | first2 = T. | last3 = Anderson | first3 = MA. | last4 = Appalaneni | first4 = V. | last5 = Banerjee | first5 = S. | last6 = Cash | first6 = BD. | last7 = Fisher | first7 = L. | last8 = Harrison | first8 = ME. | last9 = Fanelli | first9 = RD. | title = The role of endoscopy in the evaluation of suspected choledocholithiasis. | journal = Gastrointest Endosc | volume = 71 | issue = 1 | pages = 1-9 | month = Jan | year = 2010 | doi = 10.1016/j.gie.2009.09.041 | PMID = 20105473 }}</ref> and the American Gastroenterological Association (AGA).<ref name="Carr-Locke-2006">{{Cite journal  | last1 = Carr-Locke | first1 = DL. | title = Cholelithiasis plus choledocholithiasis: ERCP first, what next? | journal = Gastroenterology | volume = 130 | issue = 1 | pages = 270-2 | month = Jan | year = 2006 | doi = 10.1053/j.gastro.2005.12.010 | PMID = 16401489 }}</ref>
   
   
{{familytree/start |summary=Cholelithiasis}}
{{familytree/start |summary=Asymptomatic choledocholithiasis }}
{{familytree | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | |A01=<div style="float: left; text-align: left; line-height: 150% ">'''Characterize the symptoms:''' <br> ❑ Symptomatic <br> ❑ Aymptomatic </div> }}
{{familytree | | | | A01 | | | | A01= <div style="float: left; text-align: left ">'''Incidental bile duct stones'''<br>❑ On noninvasive imaging for nonbiliary indications<BR>❑ During evaluation of symptomatic cholelithiasis<BR>❑ Intraoperatively during cholecystectomy </div>}}
{{familytree | | | | | | | | | |,|-|-|-|^|-|-|-|.| | | | | | | | | | | | | | | | | }}
{{familytree | |,|-|-|^|-|-|.| }}
{{familytree | | | | | | | | | B01 | | | | | | B02 | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; line-height: 150% ">'''Symptomatic:'''<br> ❑ Abdominal pain</div>|B02=<div style="float: left; text-align: left; line-height: 150% ">'''Asymptomatic:'''<br> Bile duct stones discovered incidentally<br>❑ On noninvasive imaging for nonbiliary indications<BR>❑ During evaluation of symptomatic cholelithiasis<BR>❑ Intraoperatively during cholecystectomy </div>}}
{{familytree | B01 | | | | B02 | | | B01='''CBD stones discovered'''<br> '''during imaging'''| B02= '''CBD stones discovered'''<br> '''during cholecystectomy'''}}
{{familytree | | | | | | | | | |!| | | | | | | |!| | | | | | | | |}}
{{familytree | |!| | | |,|-|^|-|.| | }}
{{familytree | | | | | | | | | C01 | | | | | | C02 | |C01=<div style="float: left; text-align: left; line-height: 150% ">❑ Acute or intermittent RUQ or epigastric pain<br>❑ Sharp, severe and steady pain<br>❑ Pain >6 hours<br>❑ Pain radiating to the right shoulder blade<br>❑ Pain radiating to the back<br>❑ Pain after food intake<br>❑ Jaundice<br>❑ Pale stools<br>❑ Dark urine<br>❑ Fever<br>❑ Nausea & vomiting<br>❑ Diaphoresis<br>❑ Altered mental status<br>❑ history of recurrent symptoms<br>❑ history of previous GB disease</div>|C02='''Asymptomatic choledocholithiasis'''}}
{{familytree | C01 | | C02 | | C03 | C01= ❑ Preoperative [[ERCP]] and <br> CBD stone removal, '''and''' <br> ❑ Elective cholecystectomy| C02= ❑ Intraoperative CBD exploration <br> and stone removal| C03= ❑ Postoperative ERCP and <br>CBD stone removal}}
{{familytree | | | | | | | | | |!| | | | | |,|-|^|-|.| | | |}}
{{familytree/end}}
{{familytree | | | | | | | | | D01 | | | | D02 | | D03 | | | |D01=<div style="float: left; text-align: left; line-height: 150% ">'''Examine the patient:'''<BR>❑ Altered mental status<BR>❑ [[Fever]]<br>❑ [[Dehydration]]<BR>❑ [[Jaundice]]<BR>❑ [[Hypotension]]<BR>❑ [[Tachycardia]]<BR>❑ [[Dyspnea]]<BR>❑ [[Hypoxemia]]<BR>❑ Abdominal tenderness</div>|D02=CBD stones discovered during imaging|D03=CBD stones discovered during cholecystectomy}}
<br>
{{familytree | | | | | | | | | |!| | | | | |!| | | |!| | | |}}
 
{{familytree | | | | | | | | | E01 | | | | E02 | | E03 | | | | | |E01=<div style="float: left; text-align: left; line-height: 150% ">'''Order laboratory tests:'''<br>❑ CBC<br>❑ BMP<br>❑ CRP<br>❑ Total bilirubin<br>❑ Direct bilirubin<br>❑ Albumin<br>❑ AST<br>❑ ALT<br>❑ Alkaline phosphatase<br>❑ GGT<br>❑ Amylase<br>❑ Lipase</div>|E02=Preoperative [[ERCP]] & CBD stone removal, & elective cholecystectomy|E03=Intraoperative CBD exploration & stone removal or postoperative ERCP & CBD stone removal}}
===Symptomatic Choledocholithiasis===
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | |}}
Shown below is an algorithm depicting the management of symptomatic cholelithiasis and suspected choledocholithiasis according to the American Society for Gastrointestinal Endoscopy (ASGE)<ref name="Maple-2010">{{Cite journal  | last1 = Maple | first1 = JT. | last2 = Ben-Menachem | first2 = T. | last3 = Anderson | first3 = MA. | last4 = Appalaneni | first4 = V. | last5 = Banerjee | first5 = S. | last6 = Cash | first6 = BD. | last7 = Fisher | first7 = L. | last8 = Harrison | first8 = ME. | last9 = Fanelli | first9 = RD. | title = The role of endoscopy in the evaluation of suspected choledocholithiasis. | journal = Gastrointest Endosc | volume = 71 | issue = 1 | pages = 1-9 | month = Jan | year = 2010 | doi = 10.1016/j.gie.2009.09.041 | PMID = 20105473 }}</ref> and the American Gastroenterological Association (AGA).<ref name="Carr-Locke-2006">{{Cite journal  | last1 = Carr-Locke | first1 = DL. | title = Cholelithiasis plus choledocholithiasis: ERCP first, what next? | journal = Gastroenterology | volume = 130 | issue = 1 | pages = 270-2 | month = Jan | year = 2006 | doi = 10.1053/j.gastro.2005.12.010 | PMID = 16401489 }}</ref>
{{familytree | | | | | | | | | F01 |-|-|-| F02 |-| F03 | | | | | | |F01=<div style="float: left; text-align: left; line-height: 150% ">'''Suspect symptomatic choledocholithiasis:'''
 
{{familytree/start |summary=Symptomatic choledocholithiasis }}
{{familytree | | | | | | | | | C01 | | |C01=<div style="float: left; text-align: left; line-height: 150% "> '''Characterize the symptoms:'''<br>❑ Acute or intermittent RUQ or epigastric pain<br>
:❑ Sharp, severe and steady<br>
:❑ > 6 hours<br>
:Radiation to the right shoulder blade<br>
:Radiation to the back<br>
:After food intake<br>
[[Jaundice]]<br>❑ Pale stools<br>❑ Dark urine<br>❑ [[Fever]]<br>❑ [[Nausea]] & vomiting<br>❑ [[Diaphoresis]]<br>❑ Altered mental status<br>❑ History of recurrent symptoms<br>❑ History of previous gallbladder disease</div>}}
{{familytree | | | | | | | | | |!| | | }}
{{familytree | | | | | | | | | D01 | | D01=<div style="float: left; text-align: left; line-height: 150% ">'''Examine the patient:'''<BR>❑ Altered mental status<BR>❑ [[Fever]]<br>❑ [[Dehydration]]<BR>❑ [[Jaundice]]<BR>❑ [[Hypotension]]<BR>❑ [[Tachycardia]]<BR>❑ [[Dyspnea]]<BR>❑ [[Hypoxemia]]<BR>❑ Abdominal tenderness</div>}}
{{familytree | | | | | | | | | |!| | | }}
{{familytree | | | | | | | | | E01 | |E01=<div style="float: left; text-align: left; line-height: 150% ">'''Order laboratory tests:'''<br>❑ [[CBC]]<br>❑ [[BMP]]<br>❑ [[CRP]]<br>❑ Total [[bilirubin]]<br>❑ Direct [[bilirubin]]<br>❑ [[Albumin]]<br>❑ [[AST]]<br>❑ [[ALT]]<br>❑ Alkaline phosphatase<br>❑ [[GGT]]<br>❑ [[Amylase]]<br>❑ [[Lipase]]
----
----
'''Symptomatic & uncomplicated choledocholithiasis:'''<br>Acute or intermittent RUQ or epigastric pain, >6 hours & associated w/ nausea & vomiting<br>❑ Elevated bilirubin, alkaline phosphatase and GGT levels</div>|F02=<div style="float: left; text-align: left; line-height: 150% ">'''Symptomatic & complicated choledocholithiasis:'''<br>
❑ '''Order transabdominal USG (TAUSG)'''</div>}}
Features of symptomatic & uncomplicated choledocholithiasis w/
----
''Acute cholangitis:''<br>❑ Fever, jaundice & leukocytosis
----
''Biliary pancreatitis:''<br>❑ Elevated amylase & lipase </div>|F03=Consider severity assessment & management for acute cholangitis & biliary pancreatitis accordingly }}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | G01 | | | | | | | | | | | | | |G01='''Order transabdominal USG (TAUSG)'''}}
{{familytree | | | | | | | | | H01 | | | | | | | | | | | | | |H01=<div style="float: left; text-align: left; line-height: 150% ">'''Diagnostic predictors for the presence of common bile duct stones:'''<ref name="Maple-2010">{{Cite journal  | last1 = Maple | first1 = JT. | last2 = Ben-Menachem | first2 = T. | last3 = Anderson | first3 = MA. | last4 = Appalaneni | first4 = V. | last5 = Banerjee | first5 = S. | last6 = Cash | first6 = BD. | last7 = Fisher | first7 = L. | last8 = Harrison | first8 = ME. | last9 = Fanelli | first9 = RD. | title = The role of endoscopy in the evaluation of suspected choledocholithiasis. | journal = Gastrointest Endosc | volume = 71 | issue = 1 | pages = 1-9 | month = Jan | year = 2010 | doi = 10.1016/j.gie.2009.09.041 | PMID = 20105473 }}</ref><br>''Very strong:''<br>❑ Bilirubin >4 mg/dL<br>❑ CBD stone on TAUSG<br>❑ Clinical ascending cholangitis<div class="mw-collapsible-content"> <div class="mw-collapsible mw-collapsed">
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | H01 | | | | | | | | | | | | | |H01=<div style="float: left; text-align: left; line-height: 150% ">'''Diagnostic predictors:'''<ref name="Maple-2010">{{Cite journal  | last1 = Maple | first1 = JT. | last2 = Ben-Menachem | first2 = T. | last3 = Anderson | first3 = MA. | last4 = Appalaneni | first4 = V. | last5 = Banerjee | first5 = S. | last6 = Cash | first6 = BD. | last7 = Fisher | first7 = L. | last8 = Harrison | first8 = ME. | last9 = Fanelli | first9 = RD. | title = The role of endoscopy in the evaluation of suspected choledocholithiasis. | journal = Gastrointest Endosc | volume = 71 | issue = 1 | pages = 1-9 | month = Jan | year = 2010 | doi = 10.1016/j.gie.2009.09.041 | PMID = 20105473 }}</ref><br>''Very strong:''<br>❑ Bilirubin >4 mg/dL<br>❑ CBD stone on TAUSG<br>❑ Clinical ascending cholangitis<div class="mw-collapsible-content"> <div class="mw-collapsible mw-collapsed">
:❑ Fever
:❑ Fever
:❑ Jaundice
:❑ Jaundice
:❑ RUQ pain</div></div><br>''Strong:''<br>❑ Bilirubin 1.8-4 mg/dL<br>❑ Dilated CBD (>6 mm with GB in situ) on TAUSG<br>''Moderate:''<br>❑ Age >55 years<br>❑ Abnormal LFT other than bilirubin (elevated alkaline phosphatase & GGT)<br>❑ Clinical biliary pancreatitis<div class="mw-collapsible-content"> <div class="mw-collapsible mw-collapsed">
:❑ RUQ pain</div></div><br>''Strong:''<br>❑ Bilirubin 1.8-4 mg/dL<br>❑ Dilated CBD (>6 mm with gallbladder in situ) on TAUSG<br>''Moderate:''<br>❑ Age >55 years<br>❑ Abnormal LFT other than bilirubin (elevated alkaline phosphatase & GGT)<br>❑ Clinical biliary pancreatitis<div class="mw-collapsible-content"> <div class="mw-collapsible mw-collapsed">
:❑ Severe epigastric pain radiating to the back
:❑ Severe epigastric pain radiating to the back
:❑ Abdominal tenderness
:❑ Abdominal tenderness
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:❑ Hypotension
:❑ Hypotension
:❑ Hypoxemia</div></div></div>}}
:❑ Hypoxemia</div></div></div>}}
{{familytree | | | | | | | | | |)|-|-|-|-|-|-|-|v|-|-|-|-|-|-|-|-|-|.| | | | |}}
{{familytree | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|-|-|-|-|-|-|.| | | | |}}
{{familytree | | | | | | | | | I01 | | | | | | I02 | | | | | | | | I03 | | | | | | |I01=No predictors|I02=One strong and/or at least one moderate predictor|I03=Presence of any very strong or both strong predictors}}
{{familytree | I01 | | | | | | I02 | | | | | | | | | | I03 | | | | | | |I01='''No predictors'''|I02='''One strong and/or at least one moderate predictor'''|I03='''Presence of any very strong or both strong predictors'''}}
{{familytree | | | | | | | | | |!| | | | | | | |!| | | | | | | | | |!| | | | |}}
{{familytree | |!| | | | | | | |!| | | | | | | | | | | |!| | | | |}}
{{familytree | | | | | | | | | J01 | | | | | | J02 | | | | | | | | J03 | | | | | | |J01=Low risk|J02=Intermediate risk|J03=High risk}}
{{familytree | J01 | | | | | | J02 | | | | | | | | | | J03 | |J01= '''Low risk choledocholithiasis'''<br>|J02='''Intermediate risk choledocholithiasis'''|J03='''High risk choledocholithiasis'''}}
{{familytree | | | | | | | | | |!| | | | | |,|-|^|-|.| | | | | | | |!| | | | |}}
{{familytree | |!| | | | | |,|-|^|-|-|-|-|-|.| | | | | |!| | | | |}}
{{familytree | | | | | | | | | K01 | | |,| K02 |v| K03 |-|K04|-|-| K05 | | | | | | | |K01=GBS or biliary sludge seen during TAUSG|K02=Laparoscopic IOC or US|K03=Preoperative [[EUS]]/[[MRCP]]|K04=CBD stones present or test unavailable|K05=Preoperative ERCP & CBD stone removal}}
{{familytree | K01 | | | | K02 | | | | | | K03 | | | | K04 | | | | | | | |K01=Patient with symptomatic cholelithiasis proven by GBS or biliary sludge seen during TAUSG|K02=Laparoscopic IOC or US|K03=Preoperative [[EUS]]/[[MRCP]]|K04=Preoperative ERCP & CBD stone removal}}
{{familytree | | | | | | | | | |!| | | |!| | | |!| | | | | | | | | |!| | | |}}
{{familytree | |!| | | |,|-|^|-|.| | | |,|-|^|-|.| | | |!| |}}
{{familytree | | | | | | | | | L01 | | L02 | | L03 |-|-|-|-|-|-|-| L04 | | | | | | |L01=[[Cholecystectomy]] w/o preoperative EUS/MRCP or intraoperative cholangiography/US/CBD exploration|L02=CBD stones present|L03=CBD stones absent|L04=If GBS or sludge seen during imaging}}
{{familytree | L01 | | L02 | | L03 | | L04 | | L05 | | L06 | | |L01=<div style="float: left; text-align: left; line-height: 150% "> ❑ [[Cholecystectomy]] <br> ❑ No preoperative EUS/MRCP or intraoperative cholangiography/US/CBD exploration</div>|L02=CBD stones present|L03=CBD stones absent| L04=CBD stones present|L05=CBD stones absent| L06= If GBS or sludge seen during imaging}}
{{familytree | | | | | | | | | | | |,|-|^|-|.| | | | | | | | | | | |!| | |}}
{{familytree | | | | | |!| | | |!| | | |!| | | |!| | | |!| |}}
{{familytree | | | | | | | | | | | M01 | | M02 | | | | | | | | | | M03 | |M01=Intraoperative CBD exploration & stone removal|M02=Postoperative ERCP & CBD stone removal|M03=Elective cholecystectomy}}
{{familytree | | | | | M01 | | M02 | | M03 | | M04 | | M05 | | | | | | | M01=<div style="float: left; text-align: left; line-height: 150% ">❑ Laparoscopic CBD exploration<br> '''or''' <br>❑ Post-operative [[ERCP]]</div>|M02=❑ Laparoscopic cholecystectomy |M03= ❑ Preoperative EUS or MRCP| M04= ❑ Laparoscopic cholecystectomy| M05=❑ Elective cholecystectomy}}
{{familytree/end}}
{{familytree/end}}
<sup>†</sup>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; GB: Gallbladder; 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
 
<span style="font-size:85%">'''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 </span>
 
===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 '''[[Cholangitis resident survival guide|here]]'''.
* For the management of pancreatitis, please click '''[[Acute pancreatitis resident survival guide|here]]'''.


==Do's==
==Do's==
*Initial evaluation of suspected choledocholithiasis should include serum liver biochemical tests and a transabdominal ultrasound of the right upper quadrant.  These tests should be used to risk-stratify patients to guide further evaluation and management (Grade B).
* 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 system classification scheme|Grade B]]).<ref name="Guyatt-2008">{{Cite journal  | last1 = Guyatt | first1 = GH. | last2 = Oxman | first2 = AD. | last3 = Vist | first3 = GE. | last4 = Kunz | first4 = R. | last5 = Falck-Ytter | first5 = Y. | last6 = Alonso-Coello | first6 = P. | last7 = Schünemann | first7 = HJ. | last8 = Alderson | first8 = P. | last9 = Alonso-Coello | first9 = P. | title = GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. | journal = BMJ | volume = 336 | issue = 7650 | pages = 924-6 | month = Apr | year = 2008 | doi = 10.1136/bmj.39489.470347.AD | PMID = 18436948 }}</ref>
*EUS or MRCP can be considered in the diagnostic evaluation of postcholecystectomy patients suspected of having choledocholithiasis when initial laboratory and ultrasonography data are abnormal yet non diagnostic (Grade C).
 
*Sphincter of Oddi dysfunction should be considered as a differential diagnosis if EUS or MRCP did not detect any stones in the bile duct of postcholecystectomy patients suspected of having choledocholithiasis.
* 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 system classification scheme|Grade C]]).<ref name="Guyatt-2008">{{Cite journal  | last1 = Guyatt | first1 = GH. | last2 = Oxman | first2 = AD. | last3 = Vist | first3 = GE. | last4 = Kunz | first4 = R. | last5 = Falck-Ytter | first5 = Y. | last6 = Alonso-Coello | first6 = P. | last7 = Schünemann | first7 = HJ. | last8 = Alderson | first8 = P. | last9 = Alonso-Coello | first9 = P. | title = GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. | journal = BMJ | volume = 336 | issue = 7650 | pages = 924-6 | month = Apr | year = 2008 | doi = 10.1136/bmj.39489.470347.AD | PMID = 18436948 }}</ref>
*Laparoscopic cholecystectomy is preferred over open but conversion to open may be necessary and should not be considered a failure in management.<ref name="Duncan-2012">{{Cite journal  | last1 = Duncan | first1 = CB. | last2 = Riall | first2 = TS. | title = Evidence-based current surgical practice: calculous gallbladder disease. | journal = J Gastrointest Surg | volume = 16 | issue = 11 | pages = 2011-25 | month = Nov | year = 2012 | doi = 10.1007/s11605-012-2024-1 | PMID = 22986769 }}</ref>
 
* 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.<ref name="Duncan-2012">{{Cite journal  | last1 = Duncan | first1 = CB. | last2 = Riall | first2 = TS. | title = Evidence-based current surgical practice: calculous gallbladder disease. | journal = J Gastrointest Surg | volume = 16 | issue = 11 | pages = 2011-25 | month = Nov | year = 2012 | doi = 10.1007/s11605-012-2024-1 | PMID = 22986769 }}</ref>


==Dont's==
==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.
*Laparoscopic cholecystectomy is contraindicated in untreated coagulopathy, lack of equipment, lack of surgeon expertise, hostile abdomen, advanced cirrhosis/liver failure, and suspected gallbladder cancer.
==Grade System for Rating the Quality of Evidence==
The grade system for rating the quality of evidence is as follows.<ref name="Overby-2010">{{Cite journal  | last1 = Overby | first1 = DW. | last2 = Apelgren | first2 = KN. | last3 = Richardson | first3 = W. | last4 = Fanelli | first4 = R. | last5 = Overby | first5 = DW. | last6 = Apelgren | first6 = KN. | last7 = Beghoff | first7 = KR. | last8 = Curcillo | first8 = P. | last9 = Awad | first9 = Z. | title = SAGES guidelines for the clinical application of laparoscopic biliary tract surgery. | journal = Surg Endosc | volume = 24 | issue = 10 | pages = 2368-86 | month = Oct | year = 2010 | doi = 10.1007/s00464-010-1268-7 | PMID = 20706739 }}</ref>
{|class="wikitable"
!Quality of evidence!! Definition
|-
| High quality (Grade A)|| Further research is very unlikely to change our confidence in the estimate of effect.
|-
| Moderate quality (Grade B) || Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
|-
| Low quality (Grade C) || Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
|-
| Very low quality (Grade D)|| Any estimate of effect is very uncertain.
|}


==References==
==References==

Latest revision as of 14:48, 12 March 2014

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. doi:10.1016/j.gie.2009.09.041. PMID 20105473. 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. doi:10.1053/j.gastro.2005.12.010. PMID 16401489. 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. doi:10.1136/bmj.39489.470347.AD. PMID 18436948. 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. doi:10.1007/s11605-012-2024-1. PMID 22986769. Unknown parameter |month= ignored (help)


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