From the Guidelines
Choledocholithiasis should be managed with endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy as the primary treatment, with a reported success rate of 90% 1. The initial management of choledocholithiasis includes supportive care with IV fluids, pain control with medications, and antibiotics if infection is suspected.
Key Considerations
- The mainstay of therapy for choledocholithiasis is endoscopic biliary sphincterotomy and stone extraction during ERCP 1.
- In cases of large or impacted stones, additional therapy such as lithotripsy or stone fragmentation may be required 1.
- Placement of an internal plastic stent is standard in cases of incomplete stone extraction or severe acute cholangitis to ensure adequate biliary drainage 1.
Treatment Options
- ERCP with sphincterotomy is the preferred treatment for choledocholithiasis, with a high success rate and low risk of complications 1.
- Percutaneous transhepatic cholangiography or surgical exploration may be necessary in cases where ERCP is unsuccessful or unavailable 1.
Patient Outcomes
- Prompt treatment of choledocholithiasis is essential to prevent serious complications like cholangitis or pancreatitis 1.
- Patients who undergo stone removal and cholecystectomy (if they still have their gallbladder) can expect a significant improvement in their quality of life and a reduced risk of recurrence 1.
From the Research
Definition and Diagnosis of Choledocholithiasis
- Choledocholithiasis refers to the presence of gallstones in the common bile duct 2.
- Diagnosis of choledocholithiasis can be challenging, and various imaging modalities such as ultrasound and endoscopic retrograde cholangiopancreatography (ERCP) are used 3.
- Ultrasound has limited sensitivity and specificity in diagnosing choledocholithiasis, with a sensitivity of 25% 3.
Management of Choledocholithiasis
- Therapeutic ERCP is an important adjunct to laparoscopic cholecystectomy (LC) in the management of choledocholithiasis 2.
- Single-stage procedures, such as LC with common bile duct exploration (CBDE), are a safe and effective option for managing choledocholithiasis 4.
- Intraoperative ERCP and LCBDE are two single-stage techniques that have been compared, with similar outcomes in terms of morbidity and mortality 5.
Complications of Choledocholithiasis
- Complications of choledocholithiasis can arise due to the presence of large or impacted stones, resulting in excessive stress on the basket wires or rod 6.
- Basket impaction can lead to several complications, such as cholangitis, common bile duct (CBD) perforation, and pancreatitis 6.
- Early removal of the impacted device is recommended to prevent these complications 6.
Treatment Outcomes
- Single-stage procedures have been shown to have a reduced length of stay (LoS) compared to multi-stage management 4.
- The success rate of ERCP is high, with a success rate of 93% in one study 4.
- Complication rates between ERCP and LC with CBDE are comparable, with rates of 11.7% and 9.7%, respectively 4.