What are the signs of choledocholithiasis (inflammation of the bile duct due to gallstones)?

Signs of Choledocholithiasis

The most reliable signs of choledocholithiasis include elevated liver biochemical enzymes (especially bilirubin >4 mg/dL), visualization of common bile duct stones on imaging, and dilated bile ducts, though no single sign is sufficient for diagnosis and further diagnostic tests are typically needed. 1

Clinical Presentation

Common Symptoms

• Right upper quadrant pain
• Jaundice (may be painless with multiple stones)
• Fever (suggests cholangitis)
• Nausea and vomiting

Physical Examination Findings

• Jaundice
• Right upper quadrant tenderness
• Murphy's sign (may be positive)
• Fever (in cholangitis)

Laboratory Abnormalities

• Elevated liver enzymes
  • Elevated bilirubin (direct/conjugated)
  • Elevated alkaline phosphatase (ALP)
  • Elevated gamma-glutamyl transferase (GGT)
  • Elevated transaminases (ALT, AST)
• Elevated white blood cell count (in cholangitis)

Risk Stratification

According to the modified ASGE/SAGES classification 1, patients can be stratified by risk of choledocholithiasis:

Very Strong Predictors

• Common bile duct stone visible on ultrasound
• Clinical ascending cholangitis
• Bilirubin > 4 mg/dL

Strong Predictors

• Dilated common bile duct on ultrasound (>6mm with gallbladder in situ)
• Bilirubin 1.8-4 mg/dL

Moderate Predictors

• Abnormal liver biochemical tests
• Age > 55 years
• Clinical gallstone pancreatitis

Diagnostic Imaging

Initial Imaging

• Abdominal Ultrasound: First-line imaging test 1
  • High specificity but low sensitivity for choledocholithiasis
  • Can detect dilated bile ducts (indirect sign)
  • Direct visualization of common bile duct stones is a very strong predictor 1

Advanced Imaging

• MRCP (Magnetic Resonance Cholangiopancreatography):

  • Excellent for detection of choledocholithiasis (sensitivity 85-100%, specificity 90%) 1, 2
  • Superior to CT for biliary evaluation 1
  • Non-invasive alternative to ERCP 1
  • Recommended when ultrasound is inconclusive 1, 2

• Endoscopic Ultrasound (EUS):

  • Alternative to MRCP for evaluation of distal biliary tract obstruction 1
  • Comparable accuracy to MRCP for detecting common bile duct stones 2

• ERCP (Endoscopic Retrograde Cholangiopancreatography):

  • Historically gold standard but now reserved for therapeutic intervention 1
  • Higher complication rate (pancreatitis, cholangitis, hemorrhage) 2

Important Caveats and Pitfalls

1. Normal liver enzymes do not exclude choledocholithiasis:

   • Normal liver biochemical tests have a high negative predictive value (97%), but abnormal tests have a low positive predictive value (15%) 1, 2

2. Ultrasound limitations:

   • Common bile duct stones may be missed due to overlying bowel gas 1
   • Normal bile duct diameter does not exclude choledocholithiasis 1

3. Atypical presentations:

   • Multiple stones often present with insidious onset of painless jaundice, mimicking malignancy 3
   • Solitary stones more commonly present with abrupt onset of cholangitis or pain 3

4. False negatives on imaging:

   • Stones can be missed on multiple imaging modalities including ultrasound, CT, and even MRCP 4

5. Biliary dilatation without visible cause:

   • Only 36% of patients with gallstones and dilated bile ducts without visible etiology have choledocholithiasis 5
   • Other causes include strictures, prior stone passage, or malignancy

Management Considerations

When choledocholithiasis is suspected based on the above signs:

• ERCP with sphincterotomy is the most common treatment approach 6, 7
• One-session versus two-session approaches (endoscopic plus surgical) have similar success rates 7
• Urgent biliary decompression is necessary in acute cholangitis 2

By recognizing these signs and following appropriate diagnostic pathways, clinicians can effectively identify and manage patients with choledocholithiasis, reducing the risk of complications such as cholangitis, pancreatitis, and biliary sepsis.