What is choledocholithiasis?

Choledocholithiasis: Definition and Management

Choledocholithiasis refers to the presence of stones in the common bile duct, typically occurring in 10-20% of patients with gallstones (cholelithiasis). 1 These stones usually form in the gallbladder and subsequently migrate into the common bile duct, where they cause symptoms due to biliary obstruction.

Pathophysiology and Prevalence

• Choledocholithiasis affects approximately 8-16% of patients with symptomatic gallstone disease 2
• Most common cause of non-malignant biliary obstruction 3
• Occurs in about 10% of adults with gallstones, with approximately 500,000 cholecystectomies performed annually 4
• About 18% of adults undergoing cholecystectomy have choledocholithiasis 4

Diagnostic Approach

Risk Stratification

Predictive factors for choledocholithiasis include:

• Very strong evidence:
  • Visible CBD stone on ultrasound
  • Total bilirubin >4 mg/dL
• Strong evidence:
  • CBD diameter >6mm
  • Bilirubin 1.8-4 mg/dL
• Moderate evidence:
  • Abnormal liver enzymes
  • Age >55 years
  • Clinical gallstone pancreatitis 5

Imaging Modalities

1. Ultrasound (US): First-line imaging for suspected choledocholithiasis

   • High specificity but low sensitivity for detection of common bile duct stones
   • Can identify biliary dilation and gallstones 4

2. MRI with MRCP: Gold standard non-invasive imaging

   • Sensitivity: 93%, Specificity: 96%
   • Excellent for evaluating both intra- and extrahepatic bile ducts and liver parenchyma
   • Particularly useful when ultrasound shows biliary dilation but no stones 4, 5

3. Endoscopic Ultrasound (EUS):

   • Sensitivity: 95%, Specificity: 97%
   • Particularly useful for confirming diagnosis in moderate-risk patients 5

4. Intraoperative Cholangiography:

   • Sensitivity: 87%, Specificity: 99% 5

Management Strategies

Risk-Based Approach

1. High-risk patients:

   • With cholangitis: Urgent ERCP within 24 hours
   • With high suspicion of persistent CBD stone: Early ERCP within 72 hours 5

2. Moderate-risk patients:

   • Confirmatory imaging (MRCP, EUS)
   • Proceed to ERCP if stones are confirmed 5

3. Low-risk patients:

   • No immediate intervention for CBD stones
   • Address gallbladder stones if present 5

Treatment Options

1. Endoscopic Retrograde Cholangiopancreatography (ERCP):

   • Mainstay of therapy with 90-95% success rate
   • Includes sphincterotomy and stone extraction
   • Complications (1-2% generally, up to 10% with sphincterotomy) include:
     • Pancreatitis
     • Cholangitis
     • Duodenal perforations
     • Hemorrhage
     • Contrast media allergy 5, 6

2. Large Stones (>10-15mm):

   • May require lithotripsy or stone fragmentation
   • Success rate approximately 79%
   • 30% may require multiple sessions 5

3. Surgical CBD Exploration:

   • Laparoscopic CBD exploration: 95% success rate, 5-18% complication rate
   • Open CBD exploration: Higher morbidity (20-40%) and mortality (1.3-4%) 4, 5

4. Alternative Approaches:

   • Percutaneous transhepatic approach (95-100% success)
   • Rendezvous technique for difficult cases 4, 5

Special Considerations

Elderly Patients

• Higher complication rates with sphincterotomy (up to 19% major complications, 7.9% mortality)
• Require careful consideration of alternative therapies 5

Difficult Anatomy

• Previous gastrointestinal surgeries (Billroth II, bilioenteric anastomosis)
• Anatomical anomalies (duodenal periampullary diverticulum)
• May require percutaneous approach instead of endoscopic 3

Timing of Cholecystectomy

• Patients with gallbladder in situ should undergo cholecystectomy during the same hospital admission if possible
• If not possible, cholecystectomy should be performed within 2-4 weeks after discharge to prevent recurrent biliary events 5

Outcomes

• Single-stage procedures (LC with CBDE) have shown 80% success rate with average length of stay of 3.6 days
• Multi-stage procedures (ERCP followed by cholecystectomy) have longer hospital stays (average 8.1 days) 2
• Recurrent choledocholithiasis occurs in approximately 5.6% of cases after successful treatment 6

Pitfalls to Avoid

• Delaying ERCP in patients with cholangitis (should be performed within 24 hours)
• Overlooking the need for cholecystectomy after CBD stone clearance in patients with gallbladder in situ
• Relying solely on ultrasound for diagnosis (may miss up to 50% of CBD stones)
• Failing to recognize that concurrent choledocholithiasis and cholecystolithiasis carries a worse prognosis and higher complication rates 6