What is the treatment for choledocholithiasis?

Management of Choledocholithiasis

ERCP with sphincterotomy and stone extraction is the first-line treatment for choledocholithiasis, with a 90% success rate, and should be performed promptly in cases of acute cholangitis where biliary decompression is lifesaving. 1

Initial Assessment and Risk Stratification

Choledocholithiasis requires intervention even when asymptomatic due to risks of obstructive jaundice, cholangitis, acute pancreatitis, and potentially secondary biliary cirrhosis. 1 Initial medical management should stabilize hemodynamic status and treat infections in cases of acute biliary obstruction. 1

All patients require liver biochemical tests (ALT, AST, bilirubin, ALP, GGT) and abdominal ultrasound as the initial evaluation. 2 The ASGE recommends a risk-stratified approach: 2

High-Risk Patients (>50% probability of CBD stones):

• CBD stone visualized on ultrasound 2
• Total serum bilirubin >4 mg/dL 2
• CBD diameter >6 mm with gallbladder in situ 2
• Bilirubin 1.8-4 mg/dL 2

Moderate-Risk Patients:

• Require confirmatory imaging before proceeding to ERCP 2

Diagnostic Algorithm

High-risk patients should proceed directly to preoperative ERCP, intraoperative cholangiography, or laparoscopic ultrasound depending on local expertise. 3, 2

For moderate-risk patients, obtain confirmatory imaging with: 1, 2

• MRCP (sensitivity 93%, specificity 96%) 2
• Endoscopic ultrasound (sensitivity 95%, specificity 97%) 2
• Intraoperative cholangiography (sensitivity 87%, specificity 99%) 2
• Laparoscopic ultrasound (sensitivity 87%, specificity 100%) 2

Treatment Approach

Endoscopic Management (First-Line)

ERCP with sphincterotomy and stone extraction is the mainstay of therapy with 90% success rate. 1 This is the treatment of choice for biliary decompression in patients with moderate to severe acute cholangitis. 3

For large stones (>10-15 mm), add lithotripsy or stone fragmentation, which has a 79% success rate. 1

If incomplete stone extraction occurs or in severe acute cholangitis, place an internal plastic stent to ensure adequate biliary drainage. 1

Important caveat: Endoscopic sphincterotomy carries a 6-10% major complication rate in the general population, but this increases dramatically to 19% in elderly patients with a mortality rate of 7.9%. 1 Overall ERCP complications include pancreatitis, cholangitis, duodenal perforations, hemorrhage, and contrast media allergy (1-2% of patients), increasing to 10% with sphincterotomy. 2

Surgical Management

Laparoscopic CBD exploration is preferable to sequential endoscopic duct clearance for patients already undergoing laparoscopic cholecystectomy, with success rates up to 95% and complication rates of 5-18%. 1 This "laparoscopy-first" approach allows surgeons to avoid unnecessary ERCPs in most cases and is associated with shorter hospital stays. 4

Open CBD exploration is now generally reserved for when stones cannot be managed non-surgically, as it carries 20-40% morbidity and 1.3-4% mortality. 1

Percutaneous Approaches

Percutaneous transhepatic balloon dilation with stone extraction is an alternative with success rates of 95-100% in experienced hands. 1 For difficult cases, a rendezvous technique combining percutaneous and endoscopic approaches can be used. 1 In biliary sepsis where stones cannot be primarily crossed, placement of internal/external or external biliary catheters can be lifesaving. 1

Timing of Stone Removal

CBD stones can be removed preoperatively, intraoperatively, or postoperatively with similar success rates. 3, 2 The choice depends on local expertise and availability of techniques. 3, 2

One-session treatment (simultaneous management of gallbladder and CBD stones) is characterized by shorter hospital stay and more cost benefits compared to two-session approaches, with equivalent success rates, morbidity, stone clearance, mortality, and failure rates. 5

Special Population: Pregnancy

ERCP can be performed during pregnancy for urgent indications such as choledocholithiasis and cholangitis, ideally during the second trimester as first trimester procedures are associated with poorer fetal outcomes. 1 Pregnancy is an independent risk factor for post-ERCP pancreatitis (12% vs 5% in non-pregnant women). 1 A multidisciplinary approach involving an advanced endoscopist, maternal-fetal medicine physician, neonatologist, obstetrician, and anesthesiologist is recommended. 1

Critical Pitfalls

In severe cholangitis, early interventional biliary drainage is absolutely essential for survival—delay is associated with elevated morbidity and mortality. 3 The type and timing of biliary drainage should be based on severity of clinical presentation and availability of drainage techniques. 3

Elderly patients require particular caution with endoscopic sphincterotomy due to significantly higher complication rates (19% vs 6-10% in general population). 1 However, the same risk stratification approach applies. 2