I. What every physician needs to know.
Choledocholithiasis refers to the presence of stones or sludge in the common bile duct and/or common hepatic duct. Hepatolithiasis refers to the presence of stones in the intrahepatic bile ducts and is more common in Asia in the setting of recurrent pyogenic cholangitis.
Choledocholithiasis can be symptomatic or asymptomatic, and may be present in up to 10% of patients undergoing cholecystectomies. Most cases of choledocholithiasis result from the passage of gallbladder stones through the cystic duct into the common bile duct. Stones can also form de-novo even in the absence of the gallbladder by the same pathophysiologic mechanism that is responsible for gallstone formation – biliary stasis.
II. Diagnostic Confirmation: Are you sure your patient has choledocholithiasis?
Choledocholithiasis may be suspected in patients presenting with abdominal pain and liver enzyme elevation. The presence of choledocholithiasis is confirmed by imaging studies such as transabdominal ultrasound (low sensitivity for choledocholithiasis in the distal common bile duct), contrast enhanced abdominal computed tomography (CT) scan, magnetic resonance cholangiopancreatography (MRCP), intraoperative cholangiogram, endoscopic ultrasound (EUS) or endoscopic retrograde cholangiopancreatography (ERCP) (fluoroscopically, by cholangioscopy or intraductal ultrasound). With widespread use of imaging it can be discovered incidentally in asymptomatic patients.
A. History Part I: Pattern Recognition:
Choledocholithiasis can present in the following ways:
- Patients with gallstone pancreatitis and persistently abnormal liver enzymes due to retained stone in the bile duct
- Patients with right upper quadrant (RUQ) or epigastric pain, symptoms of biliary colic and abnormal liver enzymes
- Stones found on intraoperative cholangiogram or intraoperative ultrasound
- Incidentally found common bile duct (CBD) stones
One or more of the patterns 1-4 may be present in the same patient.
B. History Part 2: Prevalence:
CBD stones can be present in up to 10% of patients undergoing cholecystectomies. Biliary stasis can result in primary bile duct stone formation in patients with massively dilated bile ducts and/or periampullary duodenal diverticulum. Biliary strictures can also lead to stasis and stone formation.
C. History Part 3: Competing diagnoses that can mimic choledocholithiasis.
Biliary obstruction from edema in the head of the pancreas due to acute pancreatitis, primary pancreatic malignancy, bile duct malignancy, or duodenal/ampullary neoplasms can result in presentation similar to choledocholithiasis.
Imaging can falsely report the presence of CBD stones; through poor technique with incomplete filling of bile ducts with contrast during intraoperative cholangiogram, pancreatic stones in the head of the pancreas can be misinterpreted on imaging studies as being located in the CBD.
Air in the biliary tree after sphincterotomy may be misinterpreted as choledocholithiasis on MRCP or EUS.
D. Physical Examination Findings.
Physical exam findings may be normal in the setting of asymptomatic stones. Patients with gallstone pancreatitis or cholangitis may have findings associated with those diseases. There is usually no RUQ tenderness.
E. What diagnostic tests should be performed?
Physical exam cannot confirm the presence of choledocholithiasis. There may be coexistent cholecystitis, producing RUQ findings. Patients can have physical exam findings associated with cholangitis or pancreatitis. Jaundice can be present.
1. What laboratory studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?
Liver enzymes should be performed in every patient with suspected choledocholithiasis. Aspartate transaminase (AST) and alanine transaminase (ALT) may be predominantly elevated in the acute phase of biliary obstruction.
Cholestatic pattern (elevation of bilirubin, alkaline phosphatase and gamma-glutamyl transpeptidase [GGT]) usually develops later (hours) in the course of disease if the stone is retained.
Liver enzymes can be abnormal due to a myriad of conditions and their abnormality alone cannot in itself be used to make a diagnosis of choledocholithiasis without appropriate clinical setting and supportive imaging studies. Normal liver enzymes have high negative predictive value.
2. What imaging studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?
The initial imaging study is frequently a transabdominal ultrasound. It can diagnose dilation of CBD and confirm biliary obstruction as a cause of abnormal liver enzymes. It can reliably diagnose gallstones. The distal bile duct can be covered by an air-filled duodenum or stomach making visualization of stones in that portion of bile duct unreliable.
Non-contrast CT is not a useful study for diagnosis of bile duct dilation or choledocholithiasis. Contrast-enhanced CT can more reliably show biliary dilation and mass in the head of the pancreas (especially when done with pancreas protocol). Presence of a stone on abdominal CT has a very high positive predictive value.
MRCP has sensitivity and specificity of greater than 90% for the diagnosis of choledocholithiasis. It is less reliable for stones less than 6mm in size. MRCP is not invasive and does not require oral or intravenous (IV) contrast administration if only information about choledocholithiasis is being sought.
EUS combines endoscopic visualization with ultrasound. It has a high sensitivity (89-94%) and specificity (94-95%) for choledocholithiasis. As opposed to MRCP, it maintains a high sensitivity for stones < 5 millimeters in size.
Choice of imaging study may depend on clinical presentation and pretest probability of finding a CBD stone. In patients with cholangitis, or a stone visualized by previous imaging or bilirubin of greater than 4 milligrams/deciliter (mg/dl), additional imaging may not be needed and they can proceed to ERCP.
F. Over-utilized or “wasted” diagnostic tests associated with this diagnosis.
Repeat ultrasound or MRCP may be useless tests in the clinical setting of persistent biliary obstruction or cholangitis.
III. Default Management.
Management of confirmed choledocholithiasis may be endoscopic, surgical or radiologic with percutaneous interventions.
A. Immediate management.
In patients with symptomatic cholelithiasis the strategy for diagnosis and treatment of possible choledocholithiasis depends on the pre-test likelihood.
ERCP should be performed as early as possible in the setting of cholangitis. Other high-risk features include a CBD stone identified on transabdominal ultrasound or a bilirubin level > 4 mg/dl. These patients will likely benefit from an ERCP prior to cholecystectomy.
Patients with low probability of CBD stones, normalizing liver enzymes and presence of symptomatic cholelithiasis can have cholecystectomy and intraoperative cholangiogram.
Patients felt to be an intermediate risk for choledocholithiasis may be considered for an MRCP or EUS pre-operatively or an intraoperative laparoscopic ultrasound or cholangiogram. Pre-operative management decisions should be made in conjunction with the surgeon and gastroenterologist.
B. Physical Examination Tips to Guide Management.
Improvement of pain can indicate stone passage, although stones may “float” and cause a ball valve effect, intermittently obstructing and unobstructing the biliary tree. Physical exam is not of high value in the setting of choledocholithiasis.
C. Laboratory Tests to Monitor Response to, and Adjustments in, Management.
Liver enzymes should be checked daily in patients with suspected choledocholithiasis.
D. Long-term management.
Long-term management focuses on prevention of recurrent symptomatic choledocholithiasis.
E. Common Pitfalls and Side-Effects of Management.
IV. Management with Co-Morbidities.
A. Renal Insufficiency.
ERCP can be safely performed in patients with renal insufficiency.
B. Liver Insufficiency.
Biliary sphincterotomy may be associated with high risk of bleeding in patients with coagulopathy related to hepatic insufficiency. Liver enzymes are slower to normalize in patients with underlying liver disease after appropriate treatment of choledocholithiasis.
C. Systolic and Diastolic Heart Failure.
Patients with advanced heart failure may present challenges related to sedation and anesthesia for ERCP or surgery.
D. Coronary Artery Disease or Peripheral Vascular Disease.
Careful attention should be paid to the management of antiplatelet and anticoagulation therapy in patients for whom ERCP or surgery is required. The decision on stopping these agents should be weighed carefully in multidisciplinary discussion between the hospitalist, physician planning on performing the procedure and physician who manages the patient’s anticoagulation and/or antiplatelet therapy.
E. Diabetes or other Endocrine issues.
No change in standard management.
Choledocholithiasis may occur after stenting of biliary tree in patients with malignant obstruction.
G. Immunosuppression (HIV, chronic steroids, etc.).
The decision on using periprocedural antibiotics should be left up to the physician performing the ERCP or cholecystectomy.
H. Primary Lung Disease (COPD, Asthma, ILD).
Patients with advanced lung disease may present a challenge related to sedation and anesthesia or ERCP or surgery.
I. Gastrointestinal or Nutrition Issues.
No change in standard management.
J. Hematologic or Coagulation Issues.
Biliary sphincterotomy is nearly always required to definitively treat choledocholithiasis during ERCP. The decision on anticoagulation should be weighed carefully in multidisciplinary discussion between the hospitalist, physician planning on performing the procedure and physician who manages the patient’s anticoagulation and/or antiplatelet therapy.
K. Dementia or Psychiatric Illness/Treatment.
No change in standard management.
V. Transitions of Care.
A. Sign-out considerations While Hospitalized.
B. Anticipated Length of Stay.
Length of stay in patients with choledocholithiasis may be dictated by underlying medical conditions such as pancreatitis or cholangitis. Management of patients with asymptomatic incidentally found choledocholithiasis may be done on an outpatient basis if the follow-up with gastroenterology can be arranged for shortly after discharge.
C. When is the Patient Ready for Discharge.
Patients presenting with biliary obstruction can be discharged after permanent drainage is achieved (stone removal) or when temporary drainage with percutaneous transhepatic cholangiogram (PTC) or endoscopically placed stent has been established, and future follow-up is arranged for definitive management.
D. Arranging for Clinic Follow-up.
1. When should clinic follow up be arranged and with whom.
If a temporary biliary stent or percutaneous catheter is placed during the admission, the service placing these devices (interventional radiology or gastroenterology) should clearly communicate with the patient and the hospital as to what follow-up is required. Patients should have a clear understanding that these devices are temporary and if not maintained, will result in biliary obstruction eventually.
If a cholecystectomy is performed during the course of admission, the patient should follow up with the surgeon within 2-4 weeks. Patients should see a primary care physician within 1 month.
2. What tests should be conducted prior to discharge to enable best clinic first visit.
3. What tests should be ordered as an outpatient prior to, or on the day of, the clinic visit.
If liver enzymes have not completely normalized during the inpatient stay, they should be checked during the outpatient visit as persistent abnormality may indicate a retained CBD stone that has been missed, or underlying liver disease. Follow-up imaging is not generally indicated.
E. Placement Considerations.
F. Prognosis and Patient Counseling.
VI. Patient Safety and Quality Measures.
A. Core Indicator Standards and Documentation.
B. Appropriate Prophylaxis and Other Measures to Prevent Readmission.
Patients should report any potential symptoms of ERCP (abdominal pain, fever, chills, nausea, vomiting, gastrointestinal bleeding – hematochezia, melena or hematemesis, failure of jaundice to resolve, or redevelopment of jaundice).
Maple, JT, Ben-Menachem, T, Anderson, MA. “The role of endoscopy in the evaluation of suspected choledocholithiasis”. Gastrointest Endosc. vol. 71. 2010. pp. 1-9.
Maple, JT, Ikenberry, SO, Anderson, MA. “The role of endoscopy in the management of choledocholithiasis”. Gastrointest Endosc. vol. 74 . 2011. pp. 731-44.
Lee, SH, Hwang, JH, Yang, KY. “Does sphincterotomy reduce the recurrence rate of cholangitis in patients with cholangitis and suspected of a common bile duct stone not detected by ERCP”. Gastrointest Endosc. vol. 67. 2008. pp. 51-7.
Byrne, MF, McLoughlin, MT, Mitchell, RM. “For patients with predicted low risk for choledocholithiasis undergoing laparoscopic cholecystectomy, selective intraoperative cholangiography and postoperative endoscopic retrograde cholangiopancreatography is an effective strategy to limit unnecessary procedures”. Surg Endosc. vol. 23. 2009. pp. 1933-7.
Iranmanesh, P, Frossard, JL, Mugnier-Konrad, B. “Initial cholecystectomy vs sequential common duct endoscopic assessment and subsequent cholecystectomy for suspected gallstone migration: a randomized clinical trial”. JAMA. vol. 312. 2014. pp. 137-44.
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- I. What every physician needs to know.
- II. Diagnostic Confirmation: Are you sure your patient has choledocholithiasis?
- A. History Part I: Pattern Recognition:
- B. History Part 2: Prevalence:
- C. History Part 3: Competing diagnoses that can mimic choledocholithiasis.
- D. Physical Examination Findings.
- E. What diagnostic tests should be performed?
- 1. What laboratory studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?
- 2. What imaging studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?
- F. Over-utilized or “wasted” diagnostic tests associated with this diagnosis.
- III. Default Management.
- A. Immediate management.
- B. Physical Examination Tips to Guide Management.
- C. Laboratory Tests to Monitor Response to, and Adjustments in, Management.
- D. Long-term management.
- E. Common Pitfalls and Side-Effects of Management.
- IV. Management with Co-Morbidities.
- A. Renal Insufficiency.
- B. Liver Insufficiency.
- C. Systolic and Diastolic Heart Failure.
- D. Coronary Artery Disease or Peripheral Vascular Disease.
- E. Diabetes or other Endocrine issues.
- F. Malignancy.
- G. Immunosuppression (HIV, chronic steroids, etc.).
- H. Primary Lung Disease (COPD, Asthma, ILD).
- I. Gastrointestinal or Nutrition Issues.
- J. Hematologic or Coagulation Issues.
- K. Dementia or Psychiatric Illness/Treatment.
- V. Transitions of Care.
- A. Sign-out considerations While Hospitalized.
- B. Anticipated Length of Stay.
- C. When is the Patient Ready for Discharge.
- D. Arranging for Clinic Follow-up.
- 1. When should clinic follow up be arranged and with whom.
- 2. What tests should be conducted prior to discharge to enable best clinic first visit.
- 3. What tests should be ordered as an outpatient prior to, or on the day of, the clinic visit.
- E. Placement Considerations.
- F. Prognosis and Patient Counseling.
- VI. Patient Safety and Quality Measures.
- A. Core Indicator Standards and Documentation.
- B. Appropriate Prophylaxis and Other Measures to Prevent Readmission.