What are the signs and symptoms of choledocholithiasis (gallstones in the bile ducts)?

Signs and Symptoms of Choledocholithiasis

The most common signs and symptoms of choledocholithiasis (gallstones in the bile ducts) include persistent abdominal pain, jaundice, fever, nausea, and vomiting, which should prompt immediate investigation to prevent potentially life-threatening complications. 1

Clinical Presentation

Cardinal Symptoms

• Right upper quadrant (RUQ) or epigastric pain - Often the primary presenting symptom 1
• Jaundice - Due to biliary obstruction 1
• Fever - Particularly when associated with cholangitis 1
• Nausea and vomiting - Common accompanying symptoms 1

Additional Clinical Manifestations

• Abdominal distension - Due to biliary obstruction 1
• Dark urine - High specificity (100%) for choledocholithiasis 2
• Pale colored stools - High specificity (100%) for choledocholithiasis 2
• Pruritus (itching) - Due to cholestasis 2
• Cholangitis - Characterized by fever with chills, jaundice, and RUQ pain (Charcot's triad) 1
• Choluria - Presence of bile in urine causing dark coloration 1
• Acholic stools - Light-colored stools due to absence of bile 1

Laboratory Findings

Liver Function Tests

• Elevated direct and indirect bilirubin - Indicates cholestasis 1
• Elevated liver enzymes:
  • AST (aspartate aminotransferase) and ALT (alanine aminotransferase) - Indicate hepatocellular injury 1, 2
  • ALP (alkaline phosphatase) and GGT (gamma-glutamyl transpeptidase) - More specific for biliary obstruction 1

Additional Laboratory Markers

• Elevated white blood cell count - Particularly in cases of cholangitis or inflammation 1
• Elevated CRP, PCT, and lactate - May indicate severity of inflammation and sepsis 1

Imaging Findings

Ultrasound Findings

• Dilated common bile duct (>6mm) - Common but not sufficient alone for diagnosis 1, 2
• Visualization of stones in the common bile duct - Highest specificity (100%) and positive predictive value (100%) 2
• Gallbladder abnormalities - May be present concurrently 1

Advanced Imaging

• MRCP (Magnetic Resonance Cholangiopancreatography) - Excellent for detection with sensitivity of 85-100% and specificity of 90% 1
• CT scan - May show ductal dilation and complications 1
• Endoscopic ultrasound - Highly accurate for identifying common bile duct stones 1

Clinical Scenarios and Complications

Acute Presentation

• Biliary colic - Severe pain due to transient obstruction 1
• Acute cholangitis - Life-threatening infection of the biliary system 1
• Acute pancreatitis - Due to stone impaction at ampulla of Vater 1

Chronic Presentation

• Recurrent cholangitis - Main consequence of bile duct stricture 1
• Secondary biliary cirrhosis - Long-term complication of untreated obstruction 1
• Portal hypertension - Advanced complication 1
• Liver failure - End-stage complication 1

Important Clinical Pitfalls

1. Normal liver function tests do not exclude choledocholithiasis - Further investigation may be warranted if clinical suspicion remains high 1

2. Small stones may be missed on imaging - Multiple imaging modalities may be necessary 3

3. Asymptomatic stones can cause complications - 25.3% of untreated patients may experience unfavorable outcomes 1

4. Delayed diagnosis increases morbidity - Late diagnosis can result in increased complexity of treatment and impaired quality of life 1

5. Atypical presentations are possible - Especially in elderly patients who may present with vague symptoms 1

Early recognition of these signs and symptoms is crucial for prompt diagnosis and management to prevent serious complications including cholangitis, pancreatitis, and secondary biliary cirrhosis.