What is the diagnosis and treatment for Choledocholithiasis (gallstones in the common bile duct)?

From the Guidelines

Choledocholithiasis diagnosis and treatment involve a combination of imaging modalities and endoscopic or surgical interventions. The diagnosis of choledocholithiasis, or gallstones in the common bile duct, typically involves imaging studies such as ultrasound, computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP), or endoscopic ultrasound (EUS) to visualize the biliary tract and detect stones or obstruction [ 1 ].

Diagnostic Approach

• Imaging modalities: Ultrasound is often the first-line imaging modality due to its sensitivity, specificity, and non-invasive nature [ 1, 1 ].
• Laboratory tests: Liver function tests (LFTs), particularly gamma-glutamyl transpeptidase (GGT), can aid in diagnosing choledocholithiasis, with a sensitivity of 80.6% and a specificity of 75.3% [ 1 ].

Treatment Approach

• Endoscopic retrograde cholangiopancreatography (ERCP): The gold standard for visualizing the biliary tract and treating extrahepatic biliary obstruction, with a high success rate but also a significant complication rate (pancreatitis in 3–5% of cases) [ 1, 1 ].
• Surgical intervention: May be necessary in cases where ERCP is not feasible or unsuccessful, with options including open or laparoscopic cholecystectomy and common bile duct exploration [ 1, 1 ].

Management Considerations

• Preoperative evaluation: Patients with suspected choledocholithiasis should undergo preoperative ERCP, intraoperative cholangiography, or laparoscopic ultrasound to confirm the presence of common bile duct stones [ 1 ].
• Risk assessment: Elderly patients with high risk for choledocholithiasis should undergo careful evaluation and consideration for preoperative ERCP or other diagnostic tests to minimize complications [ 1 ].

From the Research

Diagnosis of Choledocholithiasis

• The diagnosis of choledocholithiasis can be made with advanced imaging, including magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography (ERCP) 2.
• Endoscopic ultrasonography (EUS) appears to be the best imaging method for the diagnosis of choledocholithiasis, with a sensitivity of 100%, specificity of 95.4%, and accuracy of 96.9% 3.
• Magnetic resonance cholangiopancreatography (MRCP) is also an accurate technique for diagnosing choledocholithiasis, with a sensitivity of 100%, specificity of 72.7%, and accuracy of 82.2% 3.

Treatment of Choledocholithiasis

• The treatment of choledocholithiasis varies locally, but ERCP with sphincterotomy is most commonly employed with a high degree of success 2.
• Other treatment options include laparoscopic surgery, open surgery, and percutaneous techniques, which can be done gradually or in combination 4, 5.
• A single-step strategy, such as laparo-endoscopic rendezvous, has gained acceptance due to lesser morbidity and a lower risk of iatrogenic damage 6.
• The choice of treatment depends on the individual patient's condition, and a tailored approach relying on careful evaluation of the disease is necessary to minimize complication risks and overall costs 6.

Management Options

• Surgery is a curative therapy for cholelithiasis concomitant with choledocholithiasis 4.
• ERCP followed by laparoscopic cholecystectomy is the preferred mode of management, but the debate remains open, with no consensus on the superiority of laparo-endoscopic rendezvous to more conventional approaches 6.
• Intraoperative cholangiography during cholecystectomy can be used routinely or selectively to diagnose CBD stones, and intraoperative bile duct exploration, either laparoscopic or open, is a commonly used intervention for CBD stones 5.