Choledocholithiasis

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Background

  • Occurs when stone expelled from gallbladder becomes impacted in the common bile duct
  • If infected, becomes Cholangitis

Anatomy & Pathophysiology

  • Gallstones are classified as cholesterol stones and pigmented stones (black and brown), and are present in approx 20% of females and 8% of males in the United States
  • These stones cause the majority of all biliary tract problems, and depending on where the stone become impacted, specific problems occur.
  • Bile flows out the gallbladder, down the cystic duct into the common bile duct, and ultimately into the 1st portion of the duodenum.

Gallbladder disease types

Gallbladder anatomy (overview).
Gallbladder anatomy

Clinical Features

  • RUQ pain
    • Radiation to the right shoulder (phrenic nerve irritation)
    • Early pain characterized as colicky, intermittent
    • Once impacted, is constant and severe
  • Nausea and Vomiting
  • Jaundice/scleral icterus
    • Caused by buildup of direct bilirubin in blood

Differential Diagnosis

RUQ Pain

Evaluation

  • LFTs, lipase, and basic chemistry
  • Imaging
    • RUQ Ultrasound
      • Noninvasive and quick
      • Common bile duct < 6 mm plus 1mm per decade after 60 yrs old
      • US is highly sensitive and specific for acute cholecystitis, much less sensitive/specific in identifying cholelithiasis due to exam limitations (i.e. difficulty identifying the CBD)
    • ERCP - highly sensitive and specific, also therapeutic
    • MRCP - comparable sensitivity/specificity to ERCP
    • HIDA Scan - not useful, as IDA (technetium 99m-labeled iminodiacetic acid) can still go into gallbladder

Management

Disposition

  • Admission to medical services
    • Consult to GI for spherincerotomy and stone removal vs General Surgery for operative management
    • Strong predictors for choledocholithiasis on ERCP[1]:
      • Clinical ascending cholangitis
      • CBD stones on US
      • Total bilirubin > 4 mg/dL

See Also

External Links

References

  1. Magalhaes J et al. Endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis: From guidelines to clinical practice. Feb 2015. World J Gastrointest Endosc. 2015 Feb 16; 7(2): 128–134.