II. Definitions

  1. Choledocholithiasis
    1. Gallstone in the Common Bile Duct
  2. Gallstone Pancreatitis
    1. Occurs when Common Bile Duct Stone obstructs the sphincter of oddi
    2. See Acute Pancreatitis

III. Epidemiology

  1. Occurs in 6-12% (up to 20%) of patients with Symptomatic 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)
    1. See Acute Pancreatitis
    2. Presents with Epigastric Pain, back pain, Vomiting and elevated serum Lipase

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 serum Lipase if Gallstone Pancreatitis present

VI. Imaging

  1. Right Upper Quadrant Ultrasound
    1. Common bile duct dilitation >6 mm (some guidelines use 8 mm cut-off)
    2. Efficacy: LR+ 8.1, LR- 0.3
  2. Magnetic Resonance Cholangiopancreatography (MRCP)
    1. Indicated where the Ultrasound and lab findings are non-diagnostic for a suspected Common Duct Stone
    2. Test Sensitivity 84% and Test Specificity 92% is more accurate than RUQ Ultrasound
  3. Endoscopic Ultrasound
    1. Test Sensitivity 94% and Test Specificity 89% (more accurate than RUQ Ultrasound and MRCP)
    2. Invasive study, but ERCP with stone removal, stenting or biopsy may be performed during the same procedure
    3. Complications in 4 to 10% include Acute Pancreatitis, acute cholangitits, bowel perforation and Upper GI Bleed
  4. References
    1. De Castro (2016) Endosc Ultrasound 5(2): 118-28 [PubMed]
    2. Giljaca (2015) Cochrane Database Syst Rev 2015(2):CD011549 +PMID: 25719224 [PubMed]
    3. Gurusamy (2015) Cochrane Database Syst Rev 2015(2):CD011548 +PMID: 25719223 [PubMed]
    4. Gurusamy (2015) Cochrane Database Syst Rev 2015(2):CD010339 +PMID: 25719222 [PubMed]

VII. Complications

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

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