From the Guidelines
The primary treatment for choledocholithiasis is endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and stone extraction, which has a reported success rate of 90% 1. This procedure is the gold standard first-line approach, allowing direct visualization and removal of stones from the common bile duct. Prior to ERCP, patients typically receive antibiotics such as piperacillin-tazobactam 3.375g IV every 6 hours or ciprofloxacin 400mg IV twice daily plus metronidazole 500mg IV every 8 hours if cholangitis (bile duct infection) is present. For pain management, NSAIDs like ketorolac 30mg IV or opioids such as morphine 2-4mg IV may be administered. Some key points to consider in the treatment of choledocholithiasis include:
- The use of lithotripsy or stone fragmentation may be required for large (>10-15 mm) impacted stones, with a reported success rate of 79% 1.
- In cases of incomplete stone extraction or severe acute cholangitis, placement of an internal plastic stent is standard to ensure adequate biliary drainage 1.
- Alternative approaches, such as percutaneous transhepatic cholangiography (PTC) with stone extraction or surgical common bile duct exploration, may be considered if ERCP is unavailable or unsuccessful 1.
- Laparoscopic bile duct exploration (LBDE) is also a viable option, with high rates of duct clearance and favorable long-term results 1.
- Following successful stone removal, cholecystectomy is recommended if the gallbladder is still present to prevent recurrence, as most bile duct stones originate from the gallbladder. Prompt treatment is essential as complications of untreated choledocholithiasis include cholangitis, pancreatitis, and biliary cirrhosis.
From the Research
Treatment Options for Choledocholithiasis
- Endoscopic retrograde cholangiopancreatography (ERCP) is a highly effective method for managing common bile duct stones, with a success rate of stone clearance of 96.2% 2.
- Biliary sphincterotomy, combined with the use of various accessories such as mechanical lithotriptors, can effectively remove most common bile duct stones 3.
- The combination of biliary sphincterotomy and papillary balloon dilation allows for the removal of many stones without the need for mechanical lithotripsy 3.
- Large stones may require additional expertise and the use of cholangioscopy with intraductal lithotripsy, while some patients may need the help of an interventional radiologist or a biliary surgeon 3.
Surgical Techniques
- Choledochotomy with primary closure is a safe technique for extracting stones from the common bile duct, with a low morbidity rate of 15% and a biliary complication rate of 7.5% 2.
- Laparoscopic common bile duct exploration (LCBDE) with primary closure is an effective treatment for choledocholithiasis, with a success rate of stone clearance of 96.2% and no mortality or CBD stricture rate 2.
Role of ERCP
- ERCP is a minimally invasive procedure for removing common bile duct stones, but it is associated with adverse events in 6% to 15% of cases 4.
- The American Society for Gastrointestinal Endoscopy (ASGE) provides evidence-based recommendations for the endoscopic evaluation and treatment of choledocholithiasis, including the use of ERCP and other endoscopic techniques 4.
- ERCP can be used in various scenarios, including selective preoperative ERCP, intraoperative ERCP, and postoperative ERCP, to remove common bile duct stones 5.