From the Guidelines
The primary treatment for choledocholithiasis is endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and stone extraction, which has a reported success rate of 90% 1. The management of choledocholithiasis involves a stepwise approach beginning with diagnosis confirmation through imaging studies like ultrasound, MRCP, or ERCP, followed by definitive treatment.
Key Considerations
- Prior to ERCP, patients should receive antibiotics if cholangitis is suspected, typically with piperacillin-tazobactam 3.375g IV every 6 hours or ciprofloxacin 400mg IV every 12 hours plus metronidazole 500mg IV every 8 hours.
- Pain management with NSAIDs or opioids and IV fluid resuscitation are important supportive measures.
- For difficult stones, mechanical lithotripsy, electrohydraulic lithotripsy, or laser lithotripsy may be necessary during ERCP.
- If ERCP fails or isn't available, percutaneous transhepatic cholangiography (PTC) or surgical common bile duct exploration are alternative options.
- Laparoscopic common bile duct exploration with cholecystectomy can be performed in a single procedure for patients with concurrent gallbladder stones.
- Recurrence prevention includes cholecystectomy if the gallbladder is present and, in select cases, ursodeoxycholic acid 8-10mg/kg/day to dissolve small residual stones.
Treatment Outcomes
- Endoscopic biliary decompression by nasobiliary catheter or indwelling stent was equally effective for patients with acute suppurative cholangitis caused by bile duct stones 1.
- Percutaneous biliary drainage (PTBD) should be reserved for patients in whom ERCP fails 1.
- Open drainage should only be used in patients for whom endoscopic or percutaneous trans-hepatic drainage is contraindicated or those in whom it has been unsuccessfully performed 1.
Recent Guidelines
- The American College of Radiology recommends an endoscopic internal biliary catheter with a removable plastic stent as an initial therapeutic procedure for patients with dilated bile ducts from choledocholithiasis 1.
- The World Journal of Emergency Surgery recommends ERCP as the treatment of choice for biliary decompression in patients with moderate/severe acute cholangitis 1.
From the Research
Management of Choledocholithiasis
The management of choledocholithiasis involves several approaches, including endoscopic, surgical, and laparoscopic methods.
- Endoscopic retrograde cholangiopancreatography (ERCP) is a primary management strategy for choledocholithiasis, allowing for the removal of stones from the common bile duct (CBD) 2, 3, 4.
- Intraductal ultrasonography (IDUS) can be useful in detecting occult CBD stones that are not visible on ERCP, especially in patients with dilated CBD 2.
- Laparoscopic common bile duct exploration (LCBDE) is an effective method for treating choledocholithiasis, allowing for the management of CBD stones in one stage, although it requires advanced laparoscopic skills and equipment 5.
- Acute cholangitis, a complication of choledocholithiasis, requires urgent biliary drainage, which can be achieved through ERCP, percutaneous transhepatic biliary drainage (PTBD), or surgery, with ERCP being the preferred method 3.
- The choice of management approach depends on various factors, including the patient's condition, the size and location of the stones, and the availability of expertise and equipment 5, 4.
Treatment Options
Treatment options for choledocholithiasis include:
- Endoscopic sphincterotomy and stone extraction using a Dormia basket or balloon catheter 4
- Balloon sphincteroplasty, although its use is limited due to safety concerns 4
- Mechanical lithotripsy, intraductal shock wave lithotripsy, extracorporeal shock wave lithotripsy, chemical dissolution, and biliary stenting for managing "difficult stones" 4
- Laparoscopic cholecystectomy and LCBDE, which can be used in conjunction with endoscopic methods 5, 6
Considerations
When managing choledocholithiasis, it is essential to consider the following: