Choledocholithiasis

Choledocholithiasis is the presence of one or more stones within the common bile duct.

Most stones migrate from the gallbladder. Less commonly, primary ductal stones form after biliary stasis, infection or previous biliary surgery.

Complications include acute cholangitis, gallstone pancreatitis and persistent obstructive jaundice.

The management principle is duct clearance plus definitive gallbladder treatment in patients with gallbladder stones.

Patients may be asymptomatic or develop:

• Episodic right upper quadrant or epigastric pain
• Jaundice
• Dark urine and pale stool
• Pruritus
• Gallstone pancreatitis

Fever with jaundice and abdominal pain indicates acute cholangitis until proven otherwise.

Check bilirubin, alkaline phosphatase, gamma glutamyl transferase and transaminases.

Ultrasound: first line; identify biliary dilatation or an obvious duct stone.

Proceed directly to therapeutic ERCP when there is:

• A common bile duct stone demonstrated on imaging
• Acute ascending cholangitis
• Bilirubin above 4 mg/dL, approximately 68 micromol/L, together with a dilated common bile duct.

For intermediate probability disease, use MRCP or endoscopic ultrasound rather than diagnostic ERCP.

ERCP with biliary sphincterotomy and balloon or basket extraction clears most duct stones.

Large stones can be treated with sphincterotomy followed by large balloon papillary dilation, mechanical lithotripsy or cholangioscopy guided electrohydraulic or laser lithotripsy.

If complete stone clearance cannot be achieved safely, place a temporary biliary stent and schedule definitive clearance. Stents placed for retained stones require planned removal or exchange.

Laparoscopic common bile duct exploration is an effective alternative when local expertise exists and can provide duct clearance and cholecystectomy during one anaesthetic.

After successful ERCP for gallbladder derived stones, perform laparoscopic cholecystectomy during the same admission whenever clinically feasible to prevent recurrent biliary events.

Routine antibiotics are unnecessary for uncomplicated choledocholithiasis when the biliary system is not infected and drainage is complete.

In gallstone pancreatitis, urgent ERCP is unnecessary unless there is accompanying cholangitis or persistent evidence of biliary obstruction.