choledocholithiasis; biliary stone
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Introduction
The presence of a gallstone in the common bile duct.
Etiology
- 20% of patients with cholecystitis
Pathology
- dilation of the common bile duct is common, typically > 6 mm in diameter
- commonly, stones impact distally in the ampulla of Vater[7]
Clinical manifestations
- may be asymptomatic[3]
- < 50% of patients develop symptoms[2]
- may cause obstructive jaundice
- biliary colic indistinguishable from that caused by cystic duct stones[7]
- right upper quadrant pain or epigastric pain
- pain may radiate to the back or right shoulder
- episodes of pain lasting 30 minutes to 3 hours[2]
- nausea/vomiting may occur
- also see cholecystitis, cholangitis & acute pancreatitis
Laboratory
- liver function tests
- elevated serum aspartate aminotransferase (serum AST)
- elevated serum alanine aminotransferase (serum ALT)
- elevated serum bilirubin*
- elevated serum alkaline phosphatase*
* serum bilirubin & serum alkaline phosphatase increased more so than serum ALT & serum AST
Diagnostic procedures
- initial evaluation: right upper quadrant ultrasound
- dilation of the common bile duct is common, typically > 6 mm in diameter[9]
- may be absent if obstruction of recent onset[7]
- dilation of the common bile duct is common, typically > 6 mm in diameter[9]
- endoscopic ultrasound (pre-op, intermediate probability)
- endoscopic retrograde cholangiopancreatography (ERCP)
- high probability/risk)* with sphincterotomy using propofol or general anesthesia[5]
- preferred method for removing common bile duct stone[2]
* clinical criteria for high risk
- visualization of stone within common bile duct on RUQ ultrasound
- clinical evidence of ascending cholangitis (fever, leukocytosis)
- serum bilirubin (total) > 4 mg/dL
- common bile duct diameter > 6 mm with an intact gallbladder & serum bilirubin (total) of 1.8 - 4.0 mg/dL[10]
Radiology
- magnetic resonance cholangiography vs endoscopic ultrasound
- common bile duct stone may occasionally be seen on abdominal ultrasound or abdominal CT[2]
* cholelithiasis on abdominal ultrasound, dilated common bile duct, total bilirubin > 1.8 mg/dL, no stone in common bile duct on ultrasound, no symptoms of ascending cholangitis[8]
Complications
(may be life-threatening)
Differential diagnosis
- cholangitis: fever, leukocytosis
- acute pancreatitis:
- fever, leukocytosis, increased serum amylase, serum lipase[2]
Management
- endoscopy (ERCP) is safer than surgery for complications
- 85-95% successful
- complications 10%
- mortality rate 1%
- use an 8-mm balloon if endoscopic papillary balloon dilation indicated
- preferred method for removing common bile duct stone[2]
- if discovered during cholecystectomy
- immediate common duct exploration, or
- endoscopic retrograde cholangiopancreatography (ERCP) postoperatively
- observation may appropriate if asymptomatic[3]
- 20% of patients sponatenously pass stones from the common bile duct[2]
- laparoscopic bile duct exploration may be associated with shorter length of stay compared with perioperative ERCP[5]
- cholecystectomy unless surgery risk is too high[5]
- consider biliary sphincterotomy & stone extraction or biliary stent as alternative.
- laparoscopic cholecystectomy after ERCP with sphincterotomy[6]
- offer laparoscopic cholecystectomy to all patients following biliary pancreatitis[5]
- operate within 2 weeks, preferably during the index admission.
- in patients with biliary pancreatitis & cholangitis or persistent obstruction, perform ERCP with stone extraction within 72 hours of presentation[5]
More general terms
Additional terms
References
- ↑ Stedman's Medical Dictionary 26th ed, Williams & Wilkins, Baltimore, 1995
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 Medical Knowledge Self Assessment Program (MKSAP) 11, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2015, 2018, 2021.
- ↑ 3.0 3.1 3.2 Journal Watch 24(4):31, 2004
Collins C et al A prospective study of common bile duct calculi in patients undergoing laparoscopic cholecystectomy: natural history of choledocholithiasis revisited. Ann Surg 239:28, 2004 PMID: https://www.ncbi.nlm.nih.gov/pubmed/14685097 - ↑ ASGE Standards of Practice Committee, Maple JT, Ben-Menachem T, Anderson MA et al The role of endoscopy in the evaluation of suspected choledocholithiasis. Gastrointest Endosc. 2010 Jan;71(1):1-9 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20105473
- ↑ 5.0 5.1 5.2 5.3 5.4 5.5 Williams E et al. Updated guideline on the management of common bile duct stones (CBDS). Gut 2017 Jan 25; <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28122906 <Internet> http://gut.bmj.com/content/early/2017/01/25/gutjnl-2016-312317
- ↑ 6.0 6.1 Elmunzer BJ, Noureldin M, Morgan KA et al. The impact of cholecystectomy after endoscopic sphincterotomy for complicated gallstone disease. Am J Gastroenterol 2017 Aug 15; PMID: https://www.ncbi.nlm.nih.gov/pubmed/28809384
- ↑ 7.0 7.1 7.2 7.3 Shalkow J Fast Five Quiz: Test Your Knowledge of Gallstones Medscape. June 12, 2018 https://reference.medscape.com/viewarticle/897845
- ↑ 8.0 8.1 8.2 NEJM Knowledge+ Question of the Week. Feb 12, 2019 https://knowledgeplus.nejm.org/question-of-week/1668/
ASGE Standards of Practice Committee, Maple JT et al The role of endoscopy in the evaluation of suspected choledocholithiasis. Gastrointest Endosc. 2010 Jan;71(1):1-9. doi:http://dx.doi.org/ 10.1016/j.gie.2009.09.041. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20105473 - ↑ 9.0 9.1 Chisholm PR, Patel AH, Law RJ et al Preoperative predictors of choledocholithiasis in patients presenting with acute calculous cholecystitis. Gastrointest Endosc. 2019 May;89(5):977-983.e2. PMID: https://www.ncbi.nlm.nih.gov/pubmed/30465770
- ↑ 10.0 10.1 NEJM Knowledge+ Gastroenterology