Choledocholithiasis

Also see Gallstones.

Clinical Features and Natural HistoryTop

Choledocholithiasis (see Figure 2 in Gallstones) is the presence of gallstones in the bile ducts. The gallstones may spontaneously pass to the duodenum, but most of them become blocked in the common bile duct or in the sphincter of Oddi.

Signs and symptoms include right epigastric pain lasting longer than biliary colic, often with concomitant jaundice, nausea, and vomiting. If the common bile duct obstruction persists, pruritus, discolored stools, and dark urine may be present. When symptoms are associated with fever and hypotension, acute cholangitis should be considered. In some cases choledocholithiasis may be asymptomatic.

DiagnosisTop

Choledocholithiasis may be suspected mainly in patients with confirmed cholelithiasis who develop jaundice and biliary colic and in patients after cholecystectomy who have recurrent pain or jaundice.

Diagnostic Tests

1. Laboratory tests: Elevated serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) in the early phase (<72 h). If obstruction persists longer, patients develop increasing serum levels of alkaline phosphatase (ALP), gamma-glutamyl transferase (transpeptidase) (GGT), and bilirubin (most frequently <180 micromol/L [10 mg/dL] with predominance of conjugated bilirubin; this depends on degree of occlusion of the common bile duct).

2. Imaging studies: Ultrasonography is the initial and frequently sufficient diagnostic method. It may reveal gallstones in the bile ducts, but more often it shows only dilatation of the bile ducts due to occlusion. Failure to visualize gallstones in the bile ducts does not exclude choledocholithiasis. Endoscopic ultrasonography (EUS) is the most precise diagnostic method that detects stones <5 mm located close to the ampulla of Vater. Magnetic resonance cholangiopancreatography (MRCP) has sensitivity and specificity in detecting stones >5 mm in diameter similar to that of EUS. Computed tomography (CT) is useful in visualizing calcified gallstones in the common bile duct. It is not the method of choice in the diagnosis of choledocholithiasis but is useful in differential diagnosis. Endoscopic retrograde cholangiopancreatography (ERCP) is not the diagnostic method of choice, as it is invasive and associated with a risk of complications (mainly acute pancreatitis; ~10%). ERCP is indicated in the setting of a very high probability of choledocholithiasis because it enables therapeutic intervention.

TreatmentTop

The diagnosis of choledocholithiasis, even in asymptomatic patients, is an indication for invasive treatment, using either endoscopy or surgery.

1. ERCP with sphincterotomy is the treatment of choice with a 90% success rate. Gallstones are retrieved into the duodenal lumen through the incised major duodenal papilla using a balloon or a wire basket. Larger stones must be fragmented prior to evacuation.

2. Extracorporeal shock wave lithotripsy (ESWL) is an auxiliary technique used for fragmentation of gallstones in case of failure of mechanical lithotripsy during ERCP.Evidence 1Weak recommendation (benefits likely outweigh downsides, but the balance is close or uncertain; an alternative course of action may be better for some patients). Low Quality of Evidence (low confidence that we know true effects of the intervention). Quality of Evidence lowered due to the observational nature of studies. Sauerbruch T, Stern M. Fragmentation of bile duct stones by extracorporeal shock waves. A new approach to biliary calculi after failure of routine endoscopic measures. Gastroenterology. 1989 Jan;96(1):146-52. PMID: 2642439. Sackmann M, Holl J, Sauter GH, Pauletzki J, von Ritter C, Paumgartner G. Extracorporeal shock wave lithotripsy for clearance of bile duct stones resistant to endoscopic extraction. Gastrointest Endosc. 2001 Jan;53(1):27-32. PMID: 11154485.

3. Stenting of the common bile duct is used when the above-listed methods are unsuccessful.Evidence 2Weak recommendation (benefits likely outweigh downsides, but the balance is close or uncertain; an alternative course of action may be better for some patients). Moderate Quality of Evidence (moderate confidence that we know true effects of the intervention). Quality of Evidence lowered due to some heterogeneity among mostly observational studies. Walter D, van Boeckel PG, Groenen MJ, et al. Cost Efficacy of Metal Stents for Palliation of Extrahepatic Bile Duct Obstruction in a Randomized Controlled Trial. Gastroenterology. 2015 Jul;149(1):130-8. doi: 10.1053/j.gastro.2015.03.012. Epub 2015 Mar 17. PMID: 25790742 Bowrey DJ, Fligelstone LJ, Solomon A, Thomas G, Shandall AA. Common bile duct stenting for choledocholithiasis: a district general hospital experience. Postgrad Med J. 1998 Jun;74(872):358-60. PMID: 9799891; PMCID: PMC2360967.

4. Surgical treatment is performed when endoscopic treatment is not feasible or has been unsuccessful. Cholecystectomy is indicated in all patients with cholelithiasis.

ComplicationsTop

Cholestatic cholangitis, acute pancreatitis, rarely biliary intestinal fistula and secondary biliary cirrhosis (in patients with chronic choledocholithiasis).