From the Guidelines
The treatment for choledocholithiasis should primarily involve endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and stone extraction, as it offers a high success rate of 90% 1. This approach allows for both diagnosis and treatment in one procedure, making it the standard of care. During ERCP, a small incision is made in the sphincter of Oddi, and stones are removed using balloon catheters or basket devices. For difficult stones, mechanical lithotripsy may be needed to fragment them before removal, with a reported success rate of 79% 1. In some cases, temporary stent placement might be necessary to ensure adequate bile drainage, especially if ERCP is unsuccessful or incomplete stone extraction occurs. If ERCP is unavailable, alternative approaches include percutaneous transhepatic cholangiography (PTC) with stone extraction or surgical bile duct exploration. For patients with gallbladders still present, cholecystectomy is typically recommended after bile duct clearance to prevent recurrent stone formation, as it reduces the incidence of subsequent cholecystitis and total biliary events 1. Patients may receive antibiotics if cholangitis (bile duct infection) is present, commonly using piperacillin-tazobactam, ciprofloxacin plus metronidazole, or other broad-spectrum options, and pain management with NSAIDs or opioids is often necessary during the acute phase 1. Key considerations in the management of choledocholithiasis include:
- Ensuring adequate biliary drainage to prevent complications such as cholangitis and pancreatitis
- Selecting the most appropriate method for stone removal based on stone size and location
- Considering the need for temporary stent placement or other interventions to ensure complete stone clearance
- Addressing the risk of recurrent stone formation through cholecystectomy when appropriate. Overall, the goal of treatment is to remove the stones, restore bile flow, and prevent recurrent stone formation and complications, with ERCP being the primary modality for achieving these goals 1.
From the Research
Treatment Options for Choledocholithiasis
The treatment for choledocholithiasis, a condition where gallstones are present in the common bile duct, can vary depending on several factors. The following are some of the treatment options:
- Endoscopic Retrograde Cholangiopancreatography (ERCP) with sphincterotomy is a commonly employed method for removing common bile duct stones, with a high degree of success 2.
- Laparoscopic cholecystectomy with common bile duct exploration is a surgical treatment option for choledocholithiasis, especially when experience is available 3.
- ERCP followed by elective cholecystectomy is considered the best therapeutic modality when experience with laparoscopic common bile duct exploration is not available 3.
- Endoscopic papillary balloon dilation (EPBD) is another option for treating choledocholithiasis, especially for stones less than 10 mm in diameter 4.
- Endoscopic biliary sphincterotomy plus papillary balloon dilation is a safe and effective treatment method for symptomatic choledocholithiasis, even during pregnancy 5.
Considerations for Treatment
When choosing a treatment option, several factors should be considered, including:
- The size and number of stones
- The presence of concurrent cholecystolithiasis (gallstones in the gallbladder)
- The patient's overall health and medical history
- The availability of experienced medical professionals and facilities
- The potential risks and complications associated with each treatment option, such as hemorrhage, cholangitis, and pancreatitis 6, 4.