What is the full inpatient management of a patient with choledocholithiasis (common bile duct stones)?

Inpatient Management of Common Bile Duct Stones

Patients diagnosed with common bile duct stones (CBDS) should be offered stone extraction as the standard of care, with evidence showing significantly better outcomes with active treatment compared to conservative management. 1

Initial Evaluation and Diagnosis

Clinical Assessment

• Evaluate for classic presentations: right upper quadrant pain, jaundice, fever (cholangitis), or acute pancreatitis
• Risk stratification into high, intermediate, or low probability of CBDS:
  • High risk: Stone identified on imaging, features of cholangitis, or triad of pain, duct dilation, and jaundice in patients with gallstones
  • Intermediate risk: CBD dilation with normal LFTs or abnormal LFTs with normal caliber biliary system
  • Low risk: Normal results 2

Laboratory Testing

• Complete blood count (FBC)
• Comprehensive liver function tests (LFTs): ALT, AST, total and direct bilirubin, alkaline phosphatase, GGT
  • Elevated bilirubin >22.23 μmol/L has 84% sensitivity and 91% specificity for biliary obstruction
  • Alkaline phosphatase >125 IU/L has 92% sensitivity and 79% specificity 2
• Coagulation profile (INR/PT) prior to any interventional procedure 1
• Blood cultures if cholangitis is suspected

Imaging Studies

• Trans-abdominal ultrasound as first-line imaging (sensitivity 32-73% for CBDS)
  • CBD diameter >6mm with gallbladder in situ is a strong predictor of CBDS
  • CBD diameter >10mm is associated with 39% incidence of CBDS 1, 2
• If initial ultrasound and LFTs are normal but clinical suspicion remains high, proceed with:
  • MRCP (sensitivity 93%, specificity 96%) as preferred second-line imaging 2
  • EUS as an alternative with similar diagnostic accuracy when MRCP is contraindicated 2

Management Approaches

Medical Management

• Intravenous fluid resuscitation
• Antibiotic therapy for cholangitis according to local guidelines
  • Broad-spectrum antibiotics covering gram-negative organisms and anaerobes
• Pain management
• Correction of coagulopathy if present

Definitive Management Options

1. Endoscopic Management (ERCP)

• Indications: High probability of CBDS, confirmed CBDS on imaging, cholangitis, biliary pancreatitis with persistent obstruction
• Procedure components:
  • Endoscopic sphincterotomy
  • Stone extraction using balloon or basket
  • For large stones (>10-15mm): mechanical lithotripsy, electrohydraulic lithotripsy (EHL), or laser lithotripsy
  • Temporary biliary stent placement if complete stone extraction is not possible 1, 2
• Special considerations:
  • Rectal NSAIDs should be administered to all patients to prevent post-ERCP pancreatitis
  • Consider pancreatic stent placement in high-risk cases (repeated pancreatic duct cannulation) 1
  • For selected patients, propofol sedation or general anesthesia improves success rates 1
  • Manage anticoagulants/antiplatelets according to BSG and ESGE guidelines 1

2. Surgical Management

• Laparoscopic bile duct exploration (LBDE):
  • Can be performed via transcystic or transductal approach during laparoscopic cholecystectomy
  • Equally effective as ERCP with shorter hospital stay 1
  • Success rates of 95-97% when performed by experienced surgeons 3
  • Preferred for patients undergoing cholecystectomy with intraoperatively discovered CBDS 1

3. Percutaneous Approaches

• Indications: Failed endoscopic or surgical approaches, altered anatomy preventing endoscopic access
• Techniques:
  • Percutaneous transhepatic cholangiography (PTC) with stone extraction
  • Percutaneous lithotripsy for large stones 4

Algorithm for Management

1. For patients with cholangitis or biliary pancreatitis with obstruction:

   • Urgent ERCP with sphincterotomy and stone extraction within 72 hours 2
   • Follow with laparoscopic cholecystectomy during same admission when clinically stable

2. For patients with confirmed CBDS without urgent indications:

   • Option A: Single-stage approach - Laparoscopic cholecystectomy with LBDE
   • Option B: Two-stage approach - ERCP with stone extraction followed by laparoscopic cholecystectomy
   • Both approaches have similar success rates, but single-stage approach may have shorter hospital stay and cost benefits 5

3. For patients with borderline CBD (6-10mm):

   • Consider conservative management with planned laparoscopic cholecystectomy and intraoperative cholangiogram
   • 90% of stones may pass spontaneously, avoiding unnecessary ERCP and its complications 6

4. For difficult stones (>15mm or impacted):

   • Consider specialized techniques: mechanical lithotripsy, electrohydraulic lithotripsy, laser lithotripsy
   • Temporary biliary stent placement if complete clearance not achieved 2

Post-Procedure Management

• Monitor vital signs, pain control, and for procedure-specific complications
• Follow-up liver function tests to confirm resolution of biliary obstruction
• For patients with temporary biliary stents, schedule stent removal/exchange
• For patients with gallbladder in situ after ERCP, schedule laparoscopic cholecystectomy to prevent recurrent biliary events 1

Management of Special Situations

Failed ERCP

• Consider LBDE if patient is undergoing cholecystectomy
• Consider percutaneous transhepatic approach if ERCP and LBDE not feasible 4

Patients with Altered Anatomy

• Balloon enteroscopy-assisted ERCP
• Percutaneous transhepatic approach
• EUS-guided biliary drainage in specialized centers 4

Complications and Their Management

• Post-ERCP pancreatitis: Aggressive IV hydration, pain control, monitoring for severe pancreatitis
• Cholangitis: Antibiotics, adequate biliary drainage
• Bleeding after sphincterotomy: Endoscopic hemostasis, angiographic embolization if severe
• Perforation: Conservative management or surgical repair depending on severity

The management of CBDS requires a multidisciplinary approach involving gastroenterologists, surgeons, and radiologists. The choice between endoscopic and surgical approaches should be based on local expertise, patient factors, and resource availability, with the goal of achieving complete stone clearance while minimizing complications 1, 7.