What is the preferred treatment for choledocholithiasis, including management of cholangitis and second‑line options if ERCP fails?

Treatment of Choledocholithiasis

ERCP with endoscopic sphincterotomy and stone extraction is the primary treatment for choledocholithiasis, achieving 90% success rates, and should be performed urgently (within 24 hours) for patients with cholangitis and severe sepsis, or within 72 hours for those with cholangitis or persistent biliary obstruction. 1

Primary Treatment Approach

Standard ERCP Management

• Endoscopic sphincterotomy with stone extraction during ERCP is the mainstay of therapy, with reported success rates of 90% for duct clearance 1, 2, 3
• For large stones (>10-15 mm) or impacted stones, additional lithotripsy or stone fragmentation is required, with lithotripsy achieving 79% success rates (though 30% may require multiple sessions) 1, 2
• When complete stone extraction cannot be achieved or in cases of severe acute cholangitis, placement of an internal plastic stent ensures adequate biliary drainage until definitive clearance 1, 2

Risk Considerations

• Endoscopic sphincterotomy carries a 6-10% major complication rate in the general population 1, 2
• In elderly patients, complication rates increase dramatically to 19% with mortality reaching 7.9%, requiring heightened caution in this population 1, 2

Management of Cholangitis

Urgent Intervention Timing

• Patients with cholangitis and severe sepsis or those deteriorating despite antibiotics require urgent ERCP within 24 hours for biliary decompression 1, 2
• For cholangitis without severe sepsis or patients with persistent biliary obstruction, perform ERCP with sphincterotomy and stone extraction within 72 hours of presentation 1
• There is no evidence supporting ERCP within 24 hours over 72 hours for stable patients, as no studies have been designed to answer this specific question 1

Antibiotic Therapy

• Initiate appropriate antibiotic therapy immediately while preparing for biliary decompression 1, 2
• Biliary decompression is lifesaving in acute cholangitis and should not be delayed 2

Second-Line Options When ERCP Fails

Percutaneous Transhepatic Approach

• When ERCP fails or is unavailable, percutaneous biliary drainage is the recommended alternative 1
• In biliary sepsis where stones cannot be crossed, placement of internal/external or external biliary catheters can be lifesaving, with 100% resolution of sepsis within 24 hours despite 17% of patients having nondilated ducts 1
• After appropriate biliary decompression, percutaneous stone removal techniques include balloon dilatation of the papilla, forceful irrigation, and balloon-tipped catheters to sweep stones into the duodenum, with success rates of 95-100% in experienced hands 1, 2

Advanced Endoscopic Techniques

• Cholangioscopy-guided electrohydraulic lithotripsy (EHL) or laser lithotripsy (LL) should be considered when standard endoscopic treatment options fail to achieve duct clearance 1
• EUS-guided placement of fully covered metallic stents has been reported for stone treatment when traditional ERCP fails, though long-term data are limited 1

Surgical Options

• Laparoscopic or open common bile duct exploration is reserved for cases where stones cannot be managed non-surgically 2
• Laparoscopic CBD exploration has success rates up to 95% with complication rates of 5-18%, compared to open exploration which carries 20-40% morbidity and 1.3-4% mortality 2

Special Techniques for Challenging Cases

Balloon Dilation Adjuncts

• Endoscopic papillary balloon dilation (EPBD) as an adjunct to sphincterotomy facilitates removal of large stones 1
• EPBD without prior sphincterotomy increases risk of post-ERCP pancreatitis but may be considered in patients with uncorrected coagulopathy or difficult biliary access; if performed alone, use an 8 mm diameter balloon 1
• For incomplete sphincterotomy, a limited sphincterotomy supplemented by EPBD is an acceptable alternative 1

Altered Anatomy

• In patients with Billroth II or Roux-en-Y anatomy, conventional endoscopes have approximately 33% success rates 1
• A combined approach using limited biliary sphincterotomy with needle knife over a stent or guidewire, followed by EPBD and stone extraction, is becoming the preferred expert method 1

Definitive Management After Stone Clearance

Cholecystectomy Timing

• Following successful endoscopic stone clearance, laparoscopic cholecystectomy should be performed to prevent recurrent biliary events 1
• For patients who are poor surgical candidates or have prohibitive operative risk, biliary sphincterotomy and endoscopic duct clearance alone is acceptable, though this is less effective than cholecystectomy for preventing recurrent complications 1
• Age and comorbidity do not significantly impact ERCP complication rates, making endoscopic management reasonable for high-risk surgical patients 1

Critical Pitfalls to Avoid

• Do not delay biliary decompression in cholangitis with severe sepsis—mortality increases significantly without urgent intervention within 24 hours 1
• Exercise extreme caution with sphincterotomy in elderly patients (age 70+), as their complication and mortality rates are substantially higher 1, 2
• Recognize that approximately 30% of patients managed with sphincterotomy alone (without cholecystectomy) will develop recurrent biliary complications during long-term follow-up 4
• Ensure coagulation parameters (INR/PT, platelet count) are checked before sphincterotomy and manage anticoagulation according to endoscopy guidelines 1