How should a patient with suspected choledocolithiasis be managed?

From the Guidelines

Patients with suspected choledocolithiasis should undergo a risk stratification approach based on clinical presentation, laboratory findings, and imaging studies to determine the best course of management. The management of suspected choledocolithiasis can be guided by the likelihood of common bile duct stones (CBDS) [ 1 ].

Risk Stratification

• Low likelihood: Consider alternative diagnosis
• Intermediate likelihood: Magnetic resonance cholangiopancreatography (MRCP) or endoscopic ultrasound (EUS) should be performed to confirm the presence of stones before proceeding to ERCP [ 1 ]
• High likelihood: Proceed to ERCP or surgical extraction

ERCP and Stone Extraction

ERCP with stone extraction is the mainstay of therapy for choledocholithiasis, with a reported success rate of 90% [ 1 ]. In cases of incomplete stone extraction or severe acute cholangitis, placement of an internal plastic stent is standard to ensure adequate biliary drainage.

Antibiotic Therapy and Cholecystectomy

Patients with cholangitis require prompt antibiotic therapy and urgent biliary decompression via ERCP [ 1 ]. Post-ERCP, patients typically receive a short course of antibiotics if stones were removed. Cholecystectomy should be performed during the same hospitalization for patients with gallbladder stones to prevent recurrence.

Key Considerations

• Prompt management is crucial to prevent complications such as cholangitis and biliary stasis.
• The choice of imaging modality and management approach should be influenced by local resources and expertise [ 1 ].

From the Research

Management of Suspected Choledocolithiasis

• The management of a patient with suspected choledocolithiasis depends on the level of suspicion, which can be categorized as high, intermediate, or low risk 2.
• High-risk patients typically present with clinical ascending cholangitis, common bile duct (CBD) stones on ultrasonography, total bilirubin > 4 mg/dL, dilated CBD on US, abnormal liver function test, age > 55 years, or gallstone pancreatitis 2.
• For patients with a high suspicion of choledocholithiasis, endoscopic retrograde cholangiography (ERC) is indicated because it allows for immediate therapy when common bile duct stones (CBDS) are identified 3.
• In cases with moderate probability of choledocholithiasis, endosonography or magnetic resonance cholangiopancreatography (MRCP) are recommended as first-line options 3.

Diagnostic Approaches

• Endoscopic ultrasonography (EUS) has been shown to have a high accuracy in detecting choledocholithiasis, with a sensitivity of 97.5% and specificity of 79.5% 4.
• EUS is particularly useful in patients with suspected CBD stones and negative computed tomography (CT) findings, as it indicates fewer procedure-related complications than ERCP and has a lower cost than MRCP 4.
• A multivariate analysis demonstrated that choledocholithiasis was strongly predicted by EUS detection of choledocholithiasis, age > 55 years, and a clinical diagnosis of cholangitis 4.

Treatment Options

• The treatment of choledocholithiasis involves the removal of the common bile duct stones, which can be achieved through ERCP, laparoscopic or open common bile duct exploration, or other modalities such as dissolving solutions, extracorporeal shockwave lithotripsy (ESWL), and laser lithotripsy 5.
• In patients with gallbladder stones and CBDS, preoperative ERC with or without endoscopic sphincterotomy (ES) is widely recommended as a standard approach, followed by laparoscopic cholecystectomy (LC) at least 24 hours later 3.
• The choice of treatment modality depends on various factors, including the patient's overall health, the presence of complications, and the availability of expertise and resources 5.

Recurrent Choledocholithiasis

• Recurrent choledocholithiasis is a significant concern, with an incidence of 27.9% within 3 years of cholecystectomy in one study 6.
• The management of recurrent choledocholithiasis poses a challenge, and the utility of EUS and MRCP in high-risk patients is being explored 6.
• Early detection and localization of stones with EUS or MRCP are recommended in complicated cases of recurrent choledocholithiasis to prevent additional invasive procedures 6.