In an adult presenting with right upper quadrant pain, jaundice, fever and elevated alkaline phosphatase and bilirubin, what is the recommended diagnostic work‑up and management for choledocholithiasis?

Diagnostic Work-Up and Management of Choledocholithiasis

In an adult presenting with right upper quadrant pain, jaundice, fever, and elevated alkaline phosphatase and bilirubin, begin immediately with right upper quadrant ultrasound and liver function tests, followed by MRCP or EUS for intermediate-probability cases, and proceed directly to ERCP with sphincterotomy and stone extraction as definitive treatment—this patient requires urgent intervention within 24 hours given the clinical picture of ascending cholangitis. 1, 2

Initial Diagnostic Approach

First-Line Testing

• Right upper quadrant ultrasound is the mandatory initial imaging study for any patient with suspected choledocholithiasis, with sensitivities ranging from 32-100% and specificities of 71-97% for detecting biliary obstruction 1
• Ultrasound confirms biliary obstruction by demonstrating dilated bile ducts and may visualize stones directly, though sensitivity for distal CBD stones is only 22.5-75% 1
• Obtain comprehensive liver function tests including total and direct bilirubin, alkaline phosphatase, ALT, AST, and GGT to confirm cholestatic pattern 1

Critical Clinical Recognition

• The triad of fever, jaundice, and RUQ pain (Charcot's triad) indicates ascending cholangitis, not simple choledocholithiasis—this is a life-threatening emergency requiring urgent biliary decompression 2, 3
• Ascending cholangitis mandates immediate resuscitation with IV fluids, broad-spectrum antibiotics, and hemodynamic stabilization before definitive intervention 2
• Do not delay intervention for additional imaging when clinical findings, laboratory values, and ultrasound showing CBD dilation with stones are present 2

Risk Stratification and Advanced Imaging

Intermediate Probability Cases

• MRCP and EUS are both highly accurate for identifying CBD stones in patients with intermediate probability of disease 1
• MRCP has 85-100% sensitivity and 90% specificity for detecting choledocholithiasis and is superior to CT for biliary pathology 1, 4
• MRCP is preferred over EUS in most centers due to wider availability, non-invasiveness, and ability to visualize the entire biliary tree 1
• EUS is limited by narrow field of view and carries up to 6.3% complication rate (primarily post-procedural pancreatitis) 1

When to Proceed Directly to ERCP

• If ultrasound demonstrates dilated CBD with cholestatic presentation, proceed directly to therapeutic ERCP without confirmatory EUS—the CBD will be presumptively swept at time of ERCP 1
• Patients with high clinical suspicion (jaundice, fever, elevated alkaline phosphatase >3x normal, bilirubin >2x normal) should undergo ERCP as both diagnostic and therapeutic procedure 1, 2

Definitive Management

Stone Extraction

• ERCP with sphincterotomy and stone extraction is the definitive treatment for choledocholithiasis, with 80-95% success rate 1, 2, 5
• All patients with confirmed CBD stones should be offered stone extraction, assuming they are fit for the procedure—conservative management results in 25.3% unfavorable outcomes versus 12.7% with active treatment 1
• Even small stones <4 mm benefit from extraction, with unfavorable outcomes of 15.9% if left untreated versus 8.9% with planned extraction 1

Timing of Intervention

• Ascending cholangitis requires urgent ERCP within 24 hours—biliary decompression is lifesaving as untreated cholangitis progresses to septic shock and death 2
• For uncomplicated choledocholithiasis without cholangitis, ERCP can be performed semi-electively but should not be indefinitely delayed 1, 5

Advanced Techniques for Difficult Cases

• Stones >15 mm often require advanced endoscopic techniques beyond standard balloon sweep 1
• Percutaneous transhepatic approaches are reserved for patients with altered anatomy (Billroth II, bilioenteric anastomosis) or failed endoscopic therapy 6

Important Clinical Pitfalls

Distinguishing Cholangitis from Simple Choledocholithiasis

• Presence of fever and systemic infection distinguishes cholangitis from simple choledocholithiasis—this mandates urgent rather than elective management 2
• Laboratory findings showing leukocytosis and elevated inflammatory markers (CRP, WBC) support cholangitis diagnosis 1, 2

Limitations of Laboratory Testing

• Alkaline phosphatase alone or in combination with bilirubin is not sufficiently predictive for choledocholithiasis and cannot replace imaging 7
• Normal ultrasound and liver function tests do not exclude choledocholithiasis if clinical suspicion remains high—proceed to MRCP 1

Post-Cholecystectomy Considerations

• Choledocholithiasis occurs in 5-15% of post-cholecystectomy patients and should be suspected with new-onset colicky RUQ pain 4
• MRCP is superior to repeat ultrasound for evaluating post-surgical biliary complications including retained stones, strictures, and bile duct injuries 4