What is the treatment for a gallstone in the bile duct?

Treatment of Gallstones in the Bile Duct

Endoscopic retrograde cholangiopancreatography (ERCP) with biliary sphincterotomy and stone extraction is the first-line treatment for gallstones in the bile duct. 1

Diagnostic Approach

• Patients with suspected common bile duct stones (CBDS) should undergo initial evaluation with transabdominal ultrasound and liver function tests, though normal results do not exclude CBDS if clinical suspicion remains high 1
• Magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound (EUS) are highly accurate diagnostic tools for confirming bile duct stones, with EUS having slightly higher sensitivity 2
• Clinical presentations that warrant investigation include right upper quadrant or epigastric pain, especially when associated with jaundice and/or fever 1

Treatment Algorithm

First-Line Treatment

• ERCP with biliary sphincterotomy and endoscopic stone extraction is the standard treatment for confirmed bile duct stones 1
• This procedure should be performed within 72 hours of presentation in patients with biliary obstruction or cholangitis 1
• For patients with signs of septic shock or deteriorating despite antibiotic therapy, urgent ERCP within 24 hours is recommended 1

Management of Difficult Stones

• For large stones (>1.5 cm), endoscopic papillary large balloon dilation with balloon extraction ± mechanical lithotripsy is recommended 3
• When conventional methods fail (occurs in 10-15% of cases), advanced techniques such as electrohydraulic or laser lithotripsy under direct cholangioscopic visualization may be necessary 3
• In cases where ERCP fails or is unavailable, percutaneous biliary drainage is an alternative treatment option 1

Surgical Considerations

• For patients with both gallbladder stones and bile duct stones, treatment options include:
  • Two-session approach: ERCP for bile duct stone removal followed by laparoscopic cholecystectomy 4
  • One-session approach: Laparoscopic common bile duct exploration with cholecystectomy (where expertise and equipment are available) 2
• The one-session approach offers shorter hospital stays and cost benefits with equivalent success rates 4

Special Considerations

• For patients with altered upper GI anatomy (e.g., Roux-en-Y gastric bypass), referral to specialized centers is recommended as endoscopic management presents significant challenges 1
• In patients with uncorrected coagulopathies, pneumatic dilation of the sphincter of Oddi may be used instead of sphincterotomy 5
• Non-surgical options like oral bile acids (ursodeoxycholic acid) are not effective for bile duct stones and are primarily used for small gallbladder stones in select patients 6

Complications and Outcomes

• Untreated bile duct stones can lead to serious complications including obstructive jaundice, acute cholangitis, pancreatitis, and secondary biliary cirrhosis 1
• A recent cohort study showed that patients with bile duct stones left in situ had a 25.3% rate of unfavorable outcomes (pancreatitis, cholangitis, bile duct obstruction) compared to 12.7% in those who underwent stone extraction 1
• Even small stones (<4 mm) benefit from extraction, with complication rates of 8.9% vs 15.9% for conservative management 1

Follow-up

• After successful stone extraction, patients with gallbladder in situ should undergo cholecystectomy during the same hospital admission or within 2-4 weeks after discharge to prevent recurrent bile duct stones 1
• In patients unfit for surgery, ERCP with sphincterotomy alone provides adequate long-term therapy 1
• Scheduled repeated ERCP may be considered for patients at high risk of recurrent bile duct stones 2