Choledocholithiasis

Introduction

-Choledocholithiasis is the presence of gallstones in the common bile duct.

-The vast majority of ductal stones are formed within the gallbladder and migrate down the cystic duct into the common bile duct. But they may also form spontaneously in the bile duct after cholecystectomy.

-About 15% of patients with gallstones have choledocholithiasis

-About 60% of common duct stones are cholesterol stones and 40% are pigment stones.

Symptoms & Signs

-Most patients with gallstones are asymmptomatic while most patients with choledocholithiasis are symptomatic.

-Biliary colic from common duct obstruction cannot be distinguished from that caused by stones in the gallbladder, but lasts longer (>5 hours).

-Choledochal stones may be silent and asymptomatic or they may cause complete or incomplete obstruction, cholangitis or gallstone pancreatitis.

-Associated symptoms:  nausea, vomiting, jaundice, pruritis (intense in warm weather and common on extremities than on trunk)

Courvoisier sign:  A palpable gallbladder due to CBD obstruction, but is also found in obstruction from malignancy.

Diagnosis

Labs: Elevated ALT, AST, amylase, lipase, alkaline phosphatase  

Imaging: Hepatobiliary ultrasound, CT, Magnetic Resonance Cholangiopancreatography, Endoscopic Retrograde Cholangiopancreatography, Percutaneous Transhepatic Cholangiogram, Endoscopic Ultrasound

-A dilated CBD on ultrasound is suggestive of choledocholithiasis.

Treatment

-The treatment is cholecystectomy with evaluation of the biliary tree and clearance of all stones within the ductal system.

-CBD stones can be removed by endoscopy or surgery.

-ERCP with sphincterotomy

– The most commonly used therapy for treatment of choledocholithiasis: Sphincterotomy

Prognosis

Major complications of choledocholithiasis: Obstructive jaundice, cholangitis, pancreatitis, and secondary biliary cirrhosis.

Q.What is the most common cause of obstructive jaundice? Bile duct stone

Q. What is the most common complication associated with endoscopic sphincterotomy? Pancreatitis

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