From the Guidelines
Choledocholithiasis is characterized by the presence of gallstones in the common bile duct, presenting with symptoms such as right upper quadrant or epigastric pain, jaundice, fever, and elevated liver enzymes, and requiring prompt intervention to prevent complications like cholangitis, pancreatitis, and secondary biliary cirrhosis. The condition is estimated to occur in 10-20% of individuals with symptomatic gallstones, and its management involves a range of diagnostic and therapeutic options, including endoscopic retrograde cholangiopancreatography (ERCP), surgery, and radiological methods of stone extraction 1. Patients with choledocholithiasis may present with biliary colic, cholangitis, or pancreatitis, and laboratory findings typically show elevated liver function tests, particularly direct bilirubin, alkaline phosphatase, and gamma-glutamyl transferase 1. Imaging studies such as ultrasound, magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasound, or ERCP are used to diagnose the condition, with ERCP serving as both a diagnostic and therapeutic tool, allowing for stone removal 1. The condition occurs when gallstones migrate from the gallbladder into the common bile duct or form primarily within the duct itself, often due to bile stasis, infection, or metabolic factors affecting bile composition. Key features of choledocholithiasis include:
- Right upper quadrant or epigastric pain
- Jaundice
- Fever
- Elevated liver enzymes
- Biliary colic
- Cholangitis
- Pancreatitis
- Dilated common bile duct on imaging studies
- Elevated liver function tests, particularly direct bilirubin, alkaline phosphatase, and gamma-glutamyl transferase. According to the most recent guidelines, the management of choledocholithiasis should prioritize ERCP as a diagnostic and therapeutic tool, given its high success rate and low complication rate 1.
From the Research
Features of Choledocholithiasis
- Constant abdominal pain, often located in the epigastrium alone or both the epigastrium and the right upper quadrant, is a common feature of choledocholithiasis 2
- The pain can radiate to the back and is often associated with nausea and vomiting 2
- Abdominal pain can occur at night and the number of distinct pain episodes before diagnosis can range from 1 to 20 2
- Liver tests are often abnormal, with serum transaminase values being most elevated 2
- Common bile duct dilatation is a common imaging finding in choledocholithiasis 2
- Choledocholithiasis can lead to biliary obstruction, cholangitis, and pancreatitis 3
- Acute bacterial cholangitis, characterized by fever, abdominal pain, and jaundice (Charcot's triad), is a potentially life-threatening condition that can occur due to common bile duct stones 4, 5
- Confusion and septic shock (Reynolds' pentad) can also occur in severe cases of acute bacterial cholangitis 4
Clinical Presentation
- The clinical presentation of choledocholithiasis can vary, but it often includes abdominal pain, nausea, vomiting, and jaundice 2, 4, 5
- The diagnosis of choledocholithiasis is often made using a combination of clinical, laboratory, and radiological findings 3, 2, 6
- Endoscopic retrograde cholangiopancreatography (ERCP) is a minimally invasive treatment for choledocholithiasis, but diagnostic ERCP should be avoided when possible 6
- Endoscopic ultrasound can be used in tandem with ERCP to confirm common bile duct stones and avoid diagnostic ERCP in some patients 6