SUPERStudy:Choledocholithiasis

By usmlevideoss

Introduction

Choledocholithiasis refers to the presence of stones in the common bile duct (CBD). These stones can lead to biliary obstruction, cholangitis, or pancreatitis, necessitating timely diagnosis and management. The most common cause of obstructive jaundice is a bile duct stone.

Etiology

  • Primary stones: Form within the bile duct, usually pigment stones, associated with stasis, infection, or parasitic infestation. 
  • Secondary stones: Originating from the gallbladder and migrating to the CBD, usually cholesterol stones. The vast majority of ductal stones are formed within the gallbladder and migrate down the cystic duct into the common bile duct. 

Risk factors include gallstones, bile duct strictures, biliary infections, and prior cholecystectomy.

Epidemiology

  • Up to 10-15% of patients with gallstones have CBD stones.
  • More common in individuals >40 years of age.
  • Higher prevalence in Asian countries due to hepatobiliary infections.

Pathophysiology

  • Stones in the CBD can obstruct bile flow, leading to elevated pressures, bile stasis, and bacterial overgrowth.
  • The obstruction may result in biliary inflammation, infection (cholangitis), or secondary pancreatitis if the pancreatic duct is involved.

Clinical Manifestations

  • Most patients with gallbladder stones are asymptomatic 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. 
  • The combination of right upper quadrant pain, fever (and chills), and jaundice represents Charcot triad and denotes the classic picture of acute cholangitis. The addition of altered mental status and hypotension (Reynolds pentad) signifies acute suppurative cholangitis and is an endoscopic emergency.
  • Other signs: Dark urine, pale stools, pruritus, and nausea/vomiting.

Severe cases may lead to sepsis or acute pancreatitis.

Diagnosis

1.Laboratory tests:

  • Elevated liver enzymes (ALT, AST, ALP, GGT).
  • Hyperbilirubinemia (conjugated).
  • Leukocytosis in infection.

2.Imaging studies:

  • Ultrasound: Initial imaging to identify bile duct dilation or stones.
  • MRCP: Non-invasive gold standard for detecting CBD stones.
  • ERCP: Diagnostic and therapeutic.

Treatment

  • Definitive management:
  • Endoscopic removal via ERCP with sphincterotomy (The most commonly used therapy for treatment of choledocholithiasis).
  • Surgical removal via bile duct exploration if ERCP is unsuccessful.
  • Supportive measures:
  • IV fluids, analgesia, and antibiotics (if infection is present).
  • Treat underlying gallstones with elective cholecystectomy after resolution.

Prognosis

  • Favorable with timely intervention.
  • Major complications of choledocholithiasis: Obstructive jaundice, cholangitis, pancreatitis, and secondary biliary cirrhosis.
  • Mortality from severe cholangitis or pancreatitis is higher without prompt treatment.

SUPERPoint

Choledocholithiasis is the presence of stones in the common bile duct, leading to biliary obstruction and potential complications like cholangitis or pancreatitis, with ERCP serving as both the diagnostic and therapeutic cornerstone.

SUPERFormula

Right upper quadrant pain + intense pruritis on extremities in warm weather + jaundice + dark urine + acholic stools + elevated alkaline phosphatase and bilirubin + dilated common bile duct on ultrasound = Choledocholithiasis

Review Questions

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

A.Bile duct stone

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

A.Pancreatitis 

References: Zucker SD. Gallstone Disease. In: Friedman S, Blumberg RS, Saltzman JR. eds. Greenberger’s CURRENT Diagnosis & Treatment Gastroenterology, Hepatology, & Endoscopy, 4e. McGraw Hill Education; 2022