Latest Guidelines for Choledocholithiasis Management
Endoscopic retrograde cholangiopancreatography (ERCP) with biliary sphincterotomy and stone extraction is recommended as the primary treatment for common bile duct stones (CBDS), with laparoscopic bile duct exploration being an equally valid alternative with similar efficacy and morbidity. 1
Diagnosis of CBDS
- Trans-abdominal ultrasound and liver function tests are recommended as initial investigations for suspected CBDS
- Normal results do not exclude CBDS if clinical suspicion remains high 1
- Additional imaging methods to consider:
- Magnetic Resonance Cholangiopancreatography (MRCP)
- Endoscopic Ultrasound (EUS)
- Intraoperative Cholangiography (IOC) or Laparoscopic Ultrasound (LUS) for patients with intermediate to high pre-test probability of CBDS 1
Endoscopic Management
ERCP Considerations
- ERCP should follow BSG national standards framework 1
- Propofol sedation or general anesthesia should be available for selected patients to improve tolerability and success rates 1
- Pre-procedure management:
Stone Extraction Techniques
- Biliary sphincterotomy is the standard approach for stone extraction 1
- For large stones, endoscopic papillary balloon dilation (EPBD) is recommended as an adjunct to sphincterotomy 1
- EPBD without sphincterotomy may be considered in patients with:
- Uncorrected coagulopathy
- Difficult biliary access due to altered anatomy
- When used alone, an 8mm diameter balloon is recommended 1
- For difficult stones, consider:
- Cholangioscopy-guided electrohydraulic lithotripsy (EHL) or laser lithotripsy (LL) when other endoscopic methods fail 1
Surgical Management
- Laparoscopic bile duct exploration (LBDE) is equally effective as perioperative ERCP for CBDS removal during cholecystectomy 1
- LBDE is associated with shorter hospital stays compared to perioperative ERCP 1
- IOC or LUS should be considered for patients with intermediate to high pre-test probability of CBDS who haven't had preoperative confirmation 1
Management in Specific Clinical Scenarios
Acute Cholangitis
- Patients with acute cholangitis who fail to respond to antibiotics or have septic shock require urgent biliary decompression 1
- Endoscopic CBDS extraction and/or biliary stenting are recommended 1
Gallstone Pancreatitis
- Patients with gallstone pancreatitis who have cholangitis or persistent biliary obstruction should undergo biliary sphincterotomy and stone extraction within 72 hours of presentation 1
- Early laparoscopic cholecystectomy should be offered to all suitable patients after gallstone pancreatitis 1
- For mild gallstone pancreatitis, cholecystectomy should be performed within 2 weeks of presentation, preferably during the same admission 1
- Patients with gallstone pancreatitis not requiring ERCP within 72 hours should be considered for elective ERCP if there is evidence of retained CBDS or if they are unsuitable for cholecystectomy 1
Altered Anatomy
- ERCP for CBDS can be performed in patients with Billroth II anatomy; a forward-viewing endoscope is recommended when duodenoscope use is difficult 1
- When biliary sphincterotomy cannot be safely completed, limited sphincterotomy with EPBD is suggested 1
- Patients with Roux-en-Y gastric bypass and CBDS should be referred to centers with advanced endoscopic and surgical capabilities 1
Post-Treatment Management
- After successful ERCP and stone clearance, patients should be monitored with liver function tests to ensure normalization 2
- Follow-up imaging may be warranted if symptoms recur 2
- Patients with recurrent bile duct stones require regular follow-up 2
Common Pitfalls to Avoid
- Failing to consider CBDS in patients with normal ultrasound findings but persistent symptoms
- Delaying biliary decompression in patients with acute cholangitis and septic shock
- Overlooking the need for early cholecystectomy after gallstone pancreatitis
- Not referring patients with altered anatomy to specialized centers