From the Guidelines
For a 32-year-old male with choledocolithiasis after cholecystectomy for cholecystitis, the recommended management is endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and stone extraction, as it has been shown to significantly reduce the risk of unfavourable outcomes, including pancreatitis, cholangitis, and obstruction of the bile duct, with a success rate exceeding 90% for common bile duct stone removal 1, 2.
Initial Workup and Preparation
The initial workup should include:
- Liver function tests
- Complete blood count
- Coagulation studies
- Imaging with abdominal ultrasound and/or MRCP (magnetic resonance cholangiopancreatography) to confirm the diagnosis and assess stone size and location The patient should be kept NPO except for medications and receive IV hydration with normal saline at 100-125 mL/hour. Pain management with hydromorphone 0.5-1mg IV every 4 hours as needed is appropriate.
ERCP Procedure
The ERCP procedure should be performed urgently, ideally within 24-72 hours of diagnosis. Prior to ERCP, the patient should receive antibiotics if there are signs of cholangitis, typically with piperacillin-tazobactam 3.375g IV every 6 hours or ciprofloxacin 400mg IV every 12 hours plus metronidazole 500mg IV every 8 hours.
Alternative Options
If ERCP is unsuccessful or unavailable, percutaneous transhepatic cholangiography (PTC) with drainage or surgical common bile duct exploration are alternative options.
Post-Procedure Care
Following successful stone removal, the patient should be observed for 24-48 hours for potential complications such as post-ERCP pancreatitis, bleeding, or perforation.
Long-Term Management
Long-term management includes a low-fat diet and ursodeoxycholic acid 8-10 mg/kg/day in divided doses for patients with recurrent stones. This approach is effective because ERCP allows direct visualization and intervention in the biliary system, with success rates exceeding 90% for common bile duct stone removal 2.
Key Considerations
- The benefits of active treatment, such as ERCP, persist even for patients with small stones (<4 mm in diameter) 1.
- Patients should be made aware that advice to undergo stone extraction is based on evidence from symptomatic patients and expert opinion 1.
From the Research
Workup for Choledocolithiasis
- Diagnosis of choledocholithiasis can be made using various imaging modalities, including ultrasound, computed tomography scans (CT), and magnetic resonance cholangiopancreatography (MRCP) 3
- Intraoperative cholangiography during cholecystectomy can be used to diagnose common bile duct (CBD) stones 3
- Laboratory tests can also be used to assess patients for choledocholithiasis 3
Management of Choledocolithiasis
- Endoscopic retrieval of common bile duct stones is the primary treatment modality for extrahepatic biliary stones 4
- However, endoscopic therapy may fail in patients with previous gastrointestinal tract surgeries or anatomical anomalies, and a percutaneous approach may be necessary 4
- Cholecystectomy is the intervention of choice for treating acute cholecystitis, and can be performed together with or after endoscopic papillotomy through endoscopic retrograde cholangiopancreatography (ERCP) 5
- The timing of cholecystectomy (before or after ERCP) does not appear to interfere with the postoperative period and clinical outcome in patients with acute cholecystitis 5
Treatment Options
- ERCP is a common intervention for CBD stones, and can be performed before or after cholecystectomy 5, 3
- Intraoperative bile duct exploration, either laparoscopic or open, is another option for treating CBD stones 3
- Percutaneous, transhepatic stone removal is a viable option for patients who are not suitable for endoscopic therapy 4
- A combined single inpatient procedure of ERCP and cholecystectomy may be a safe, efficacious, and cost-efficient approach compared to separate-session procedures 6