Choledocholithiasis

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

Bile duct and pancreas anatomy. 1. Bile ducts: 2. Intrahepatic bile ducts; 3. Left and right hepatic ducts; 4. Common hepatic duct; 5. Cystic duct; 6. Common bile duct; 7. Sphincter of Oddi; 8. Major duodenal papilla; 9. Gallbladder; 10-11. Right and left lobes of liver; 12. Spleen; 13. Esophagus; 14. Stomach; 15. Pancreas: 16. Accessory pancreatic duct; 17. Pancreatic duct; 18. Small intestine; 19. Duodenum; 20. Jejunum; 21-22: Right and left kidneys.

• Symptomatic cholelithiasis (biliary colic)
• Choledocholithiasis
• Acute calculous cholecystitis
• Ascending cholangitis
• Acalculous cholecystitis
• Biliary atresia
• Cholestasis of pregnancy

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

• Gallbladder disease
  • Acute cholecystitis
  • Cholangitis
  • Symptomatic cholelithiasis/Biliary Colic
  • Acalculous cholecystitis
  • Gallstone pancreatitis
  • Choledocholithiasis
• Peptic ulcer disease with or without perforation
• Pancreatitis
• Acute hepatitis
• Pyelonephritis
• Pneumonia
• Kidney stone
• GERD
• Appendicitis (retrocecal)
• Pyogenic liver abscess
• Fitz-Hugh-Curtis Syndrome
• Hepatomegaly due to CHF
• Herpes zoster
• Myocardial ischemia
• Bowel obstruction
• Pulmonary embolism
• Abdominal aortic aneurysm

Evaluation

RUQ ultrasound showing non-obstructing common bile duct stone.

• 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

• Pain control
• Fluid resuscitation and electrolyte repletion
• NPO
• If any concern for concomitant acute cholecystitis, start antibiotics
  • Always consider cholangitis

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:
    • Clinical ascending cholangitis
    • CBD stones on US
    • Total bilirubin > 4 mg/dL

See Also

• Gallbladder disease (main)