What are the symptoms and treatment options for Choledocholithiasis (gallstones in the common bile duct)?

From the Guidelines

The primary treatment approach for choledocholithiasis is endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and stone extraction, which has a reported success rate of 90% 1. This procedure should be performed within 24-72 hours of diagnosis, especially in patients with signs of biliary obstruction, cholangitis, or pancreatitis.

Key Considerations

• Prior to ERCP, patients should receive appropriate antibiotics such as piperacillin-tazobactam 3.375g IV every 6 hours or ciprofloxacin 400mg IV every 12 hours plus metronidazole 500mg IV every 8 hours if cholangitis is suspected 1.
• Pain management with NSAIDs or opioids may be necessary.
• For patients who are poor surgical candidates or have failed ERCP, percutaneous transhepatic cholangiography (PTC) or dissolution therapy with ursodeoxycholic acid 8-10mg/kg/day in divided doses may be considered.
• Following successful stone removal, cholecystectomy is recommended within 2-4 weeks to prevent recurrence if the patient still has their gallbladder.

Additional Therapies

• In some cases, particularly those involving large (>10-15 mm) impacted stones, additional therapy in the form of lithotripsy or stone fragmentation may be required 1.
• Lithotripsy has a reported success rate of 79%; however, upwards of 30% of patients may require multiple sessions to clear the stones completely 1.
• In cases of incomplete stone extraction or severe acute cholangitis, placement of an internal plastic stent is standard to ensure adequate biliary drainage 1.

Guideline Recommendations

• An endoscopic internal biliary catheter with a removable plastic stent is usually appropriate as an initial therapeutic procedure for patients with dilated bile ducts from choledocholithiasis 1.
• Either an endoscopic internal biliary catheter with a removable plastic stent or a percutaneous internal/external biliary catheter may be appropriate depending on the patient’s anatomy and availability of resources and institutional preferences 1.

From the Research

Diagnosis of Choledocholithiasis

• Endoscopic ultrasonography is a highly sensitive test for the detection of choledocholithiasis, with a sensitivity of 97% compared to endoscopic retrograde cholangiography (ERCP) which has a sensitivity of 67% 2.
• The size of the stone and the diameter of the common bile duct do not influence the performance of endoscopic ultrasonography in diagnosing choledocholithiasis 2.
• ERCP is a minimally invasive procedure that is highly accurate in diagnosing choledocholithiasis, but it is associated with adverse events in 6% to 15% of cases 3.

Treatment of Choledocholithiasis

• ERCP is the primary treatment for choledocholithiasis, and it involves the removal of stones from the common bile duct 3.
• Endoscopic sphincterotomy is a procedure that is often performed during ERCP to facilitate the removal of stones from the common bile duct 4.
• In some cases, laparoscopic cholecystectomy may be performed in conjunction with ERCP to remove the gallbladder and stones from the common bile duct 4.

Risk Factors for Choledocholithiasis

• Clinical predictors such as clinical ascending cholangitis, common bile duct stones on ultrasonography, total bilirubin > 4 mg/dL, dilated common bile duct on ultrasonography, abnormal liver function test, and age > 55 years are associated with an increased risk of choledocholithiasis 5, 6.
• Patients with high risk factors for choledocholithiasis have a probability of 79% of having choledocholithiasis, while those with intermediate risk factors have a probability of 41% 6.

Guidelines for the Management of Choledocholithiasis

• The American Society for Gastrointestinal Endoscopy (ASGE) has published guidelines for the evaluation and management of choledocholithiasis, which include recommendations for the use of ERCP, endoscopic ultrasonography, and other diagnostic and therapeutic procedures 3.
• The guidelines recommend that patients with suspected choledocholithiasis be stratified into low, intermediate, and high risk groups based on clinical predictors, and that ERCP be performed in patients with high risk factors 5, 6.