Retained Common Bile Duct Stone

A retained common bile duct stone is a stone left in the bile duct after cholecystectomy or common bile duct exploration, and found usually within 2 years of surgery. Stones found later are usually recurrent, with a new origin.

Retained stones occur in about 1% to 5% of cholecystectomies and up to 10% when intraoperative cholangiography is not done. They cause biliary pain, jaundice, cholangitis and pancreatitis.

Pathophysiology.

Stones missed at surgery, or migrating from the intrahepatic ducts, obstruct bile flow, and stasis promotes infection. Obstruction with infection causes ascending cholangitis, and stones at the ampulla cause gallstone pancreatitis.

Right upper quadrant pain, jaundice, dark urine and pale stools, fever with rigors (cholangitis), nausea and vomiting, and acute pancreatitis.

Red flags.

• Fever, jaundice and pain (cholangitis).
• Hypotension or confusion (severe cholangitis).
• Severe pancreatitis.

Liver tests (raised bilirubin, alkaline phosphatase, gamma glutamyl transferase and aminotransferases), lipase, full blood count, C-reactive protein and blood cultures. Ultrasound shows duct dilatation (over 6 mm, more after cholecystectomy). Magnetic resonance cholangiopancreatography or endoscopic ultrasound confirms the stone with high accuracy. Endoscopic retrograde cholangiopancreatography is reserved for treatment.

Differential diagnosis.

• Bile duct stricture.
• Cystic duct remnant syndrome.
• Papillary stenosis.
• Cholangiocarcinoma or ampullary tumour.
• Mirizzi type compression.
• Drug induced cholestasis.

Remove the stone by endoscopic retrograde cholangiopancreatography with sphincterotomy and extraction (balloon or basket). Large stones (over 15 mm) need endoscopic papillary large balloon dilation of 12 to 20 mm after sphincterotomy, or lithotripsy (mechanical, electrohydraulic or laser, often by cholangioscopy). Place a biliary stent if clearance is incomplete, and repeat the procedure.

In cholangitis, drain urgently (within 12 to 24 hours for severe disease, within 24 to 48 hours otherwise) and give antibiotics.

• Piperacillin-tazobactam: 4.5 g IV every 6 hours for 4 to 7 days after drainage; maximum 18 g daily; monitor renal function, blood counts and cultures; reduce for creatinine clearance under 40 mL/min.
• Indomethacin (prophylaxis against pancreatitis): 100 mg rectally once before or after the procedure; maximum 100 mg; monitor renal function and bleeding; avoid in peptic ulcer, renal impairment and non-steroidal drug allergy.

Percutaneous or surgical exploration is used when endoscopy fails or the anatomy is altered.

Monitoring. Liver tests 1 to 2 days and 4 to 6 weeks after treatment; vital signs after sphincterotomy for bleeding or perforation.

Referral and escalation. Pancreaticobiliary endoscopy; hepatobiliary surgery for failed clearance; critical care for severe cholangitis.