Choledocholithiasis

Aka: Choledocholithiasis, Common Bile Duct Stone, Common Duct Stone

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II. Definition

  1. Gallstone in the Common Bile Duct

III. Epidemiology

  1. Occurs in 6-12% of patients with Gallstones
  2. Common Bile Duct Stones pass spontaneously in 73% of cases

IV. Signs

  1. Biliary Colic
  2. Acute Cholecystitis
  3. Ascending Cholangitis
  4. Gallstone Pancreatitis (with Gallstone lodged at the sphincter of oddi)

V. Labs

  1. Liver Function Tests (hepatic panel)
    1. Increased transaminases
    2. Increased cholestasis labs
    3. Total Serum Bilirubin >4 mg/dl
  2. Pancreatic labs
    1. Increased Lipase if gallstone Pancreatitis present

VI. Imaging

  1. Ultrasound
    1. Common bile duct dilitation >6 mm (some guidelines use 8 mm cut-off)
  2. Magnetic Resonance Cholangiopancreatography (MRCP)
    1. Indicated where the Ultrasound and lab findings are non-diagnostic for a still suspected Common Duct Stone

VII. Complications

  1. Recurrent biliary symptoms despite Cholecystectomy
  2. Ascending Cholangitis
  3. Gallstone Pancreatitis

VIII. Management

  1. Laparoscopic Cholecystectomy and
  2. Common Bile Duct Stone removal
    1. Laparoscopic stone extraction (preferred) or
    2. Intraoperative cholangiography or
      1. Selective postoperative ERCP if stones present
    3. Preoperative ERCP and then Cholecystectomy

IX. References

  1. Abraham (2014) Am Fam Physician 89(10): 795-802 [PubMed]
  2. Portincasa (2006) Lancet 368(9531):230-9 [PubMed]
  3. Urbach (2001) Surg Endosc 15:4-13 [PubMed]

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