What is the recommended treatment for choledocholithiasis (presence of gallstones in the bile ducts)?

Treatment for Choledocholithiasis

ERCP with sphincterotomy and stone extraction is the first-line treatment for choledocholithiasis, achieving 90% success rates and should be performed urgently (within 24 hours) in patients with concomitant cholangitis or severe sepsis. 1, 2

Initial Stabilization and Risk Assessment

• Immediate biliary decompression is lifesaving in acute cholangitis and must be performed within 24 hours in patients with severe sepsis or clinical deterioration despite antibiotics 3, 2
• For gallstone pancreatitis with cholangitis or persistent biliary obstruction, perform ERCP with sphincterotomy within 72 hours of presentation 3, 2
• Initial medical management focuses on hemodynamic stabilization, fluid resuscitation, correction of electrolyte abnormalities, and treatment of systemic infections 3, 2

Diagnostic Strategy Based on Risk Stratification

High-risk patients (>50% probability) should proceed directly to therapeutic intervention: 4

• Very strong predictors: CBD stone visible on ultrasound, total bilirubin >4 mg/dL 4
• Strong predictors: CBD diameter >6 mm with gallbladder in situ, bilirubin 1.8-4 mg/dL 4
• Proceed directly to ERCP, intraoperative cholangiography, or laparoscopic ultrasound based on local expertise 1, 4

Moderate-risk patients require confirmatory imaging before intervention: 4

• Perform preoperative MRCP (93% sensitivity) or EUS (95% sensitivity) 1, 4
• Alternative options include intraoperative cholangiography (87% sensitivity) or laparoscopic ultrasound (87% sensitivity) 4

Primary Treatment: Endoscopic Management

Standard ERCP approach: 1, 2

• ERCP with sphincterotomy and stone extraction achieves 90% success in clearing the common bile duct 1, 2
• For large stones (>10-15 mm), add mechanical lithotripsy or stone fragmentation techniques (79% success rate) 1, 2
• If incomplete extraction occurs, place temporary internal plastic stent to ensure adequate biliary drainage 1

Important complication profile to discuss with patients: 1, 4

• Standard ERCP complications occur in 1-2% of patients (pancreatitis, cholangitis, perforation, hemorrhage) 4
• Risk increases to 6-10% with sphincterotomy 1, 4
• Elderly patients face nearly double the complication rate at 19% with 7.9% mortality 1, 2

Alternative Approaches When ERCP Fails or Is Contraindicated

Percutaneous transhepatic approach: 1, 2

• Achieves 95-100% success rates in experienced hands 1, 2
• Technique involves percutaneous access, balloon dilation of papilla, and pushing stones into duodenum 2
• For stones >15 mm, perform basket lithotripsy before balloon dilation 2
• Can use rendezvous technique combining percutaneous and endoscopic approaches for difficult cases 1

Surgical management (reserved for refractory cases): 1, 2

• Laparoscopic CBD exploration is now preferred over open surgery with 95% success rates and 5-18% complication rates 1, 2
• Open CBD exploration carries 20-40% morbidity and 1.3-4% mortality 1
• Generally indicated when CBD is wide (>9 mm) to avoid subsequent stricture development 2

Special Population: Pregnancy

• ERCP can be performed during pregnancy for urgent indications (choledocholithiasis with cholangitis) 1
• Ideally perform during second trimester as first trimester procedures are associated with poorer fetal outcomes 1, 2
• Pregnancy increases post-ERCP pancreatitis risk to 12% versus 5% in non-pregnant women 1
• Requires multidisciplinary team including advanced endoscopist, maternal-fetal medicine physician, neonatologist, obstetrician, and anesthesiologist 1

Treatment Algorithm

1. Assess severity: Determine presence of cholangitis, sepsis, or pancreatitis 2
2. Risk stratify: Use ASGE criteria to classify as high, moderate, or low risk 4
3. High-risk patients: Proceed directly to ERCP with sphincterotomy and stone extraction 1, 2
4. Moderate-risk patients: Obtain MRCP or EUS confirmation, then proceed to ERCP if positive 1, 4
5. Large stones: Add lithotripsy or fragmentation techniques 1, 2
6. Failed endoscopic clearance: Consider percutaneous approach or surgical CBD exploration 1, 2
7. Definitive management: Perform cholecystectomy during same admission or within 2-4 weeks after discharge 3

Critical Pitfalls to Avoid

• Never delay biliary decompression beyond 24 hours in patients with severe sepsis or deteriorating cholangitis despite antibiotics 2
• Do not perform first trimester ERCP in pregnant patients unless absolutely emergent due to poorer fetal outcomes 2
• Exercise extreme caution in elderly patients who have 19% complication rates versus 6-10% in younger patients 1, 2
• Do not assume all stones can be extracted endoscopically—have backup plan for percutaneous or surgical approach before starting the procedure 2
• Avoid unnecessary ERCP in low-risk patients as complications occur even without therapeutic intervention 4