AUTHOR AND EDITOR INFORMATION

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INTRODUCTION

Section 2 of 11  

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Background

Symptomatic cholelithiasis is a common medical problem, which makes cholecystectomy one of the most frequently performed surgical procedures in the world. Choledocholithiasis complicates the workup and management of cholelithiasis, necessitates additional diagnostic and therapeutic procedures, and adds to the morbidity and mortality of gallstone disease. Management of choledocholithiasis has been the subject of much debate over the past several years, especially with the advent of new laparoscopic techniques and greater experience with endoscopic procedures.

Pathophysiology

Choledocholithiasis occurs as a result of either the primary formation of stones in the common bile duct (CBD) or the passage of gallstones from the gallbladder through the cystic duct into the CBD. Bile stasis, bactibilia, chemical imbalances, pH imbalances, increased bilirubin excretion, and the formation of sludge are among the principal factors thought to lead to the formation of these stones.

Gallstones are differentiated by their chemical composition. Cholesterol stones are composed mainly of cholesterol, black pigment stones are mainly pigment, and brown pigment stones are made up of a mix of pigment and bile lipids. Obstruction of the CBD by gallstones leads to symptoms and complications that include pain, jaundice, cholangitis, pancreatitis, and sepsis.

Frequency

United States

The incidence rate for gallstones is 10-20%. Approximately 600,000 cholecystectomies are performed in the United States every year, and choledocholithiasis complicates 10-15% of these cases.

International

The international incidence rate is higher, mainly because of the additional problem of primary CBD stones caused by parasitic infestation with Ascaris lumbricoides and Clonorchis sinensis.

Race

Differences in etiology and incidence are observed in persons of different races. In the Asian population, infestation with A lumbricoides and C sinensis is thought to promote bile stasis and, hence, formation of primary CBD stones.

Sex

Cholelithiasis occurs more frequently in females than in males.

Age

In the United States, the incidence rate for gallstones is approximately 40% in individuals older than 60 years. In individuals undergoing cholecystectomy for symptomatic cholelithiasis, 8-15% of patients younger than 60 years have CBD stones, compared to 15-60% of patients older than 60 years.

CLINICAL

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History

Patients with choledocholithiasis may be completely asymptomatic; in approximately 7% of cases, the stones are found incidentally during cholecystectomy. Stones are seen in 1% of autopsies performed on individuals older than 60 years who died of unrelated causes. Approximately 25-50% of asymptomatic CBD stones eventually cause symptoms and require treatment. Symptoms occur when the stones obstruct the CBD. The clinical presentation varies depending on the degree and level of obstruction and on the presence or absence of biliary infection.

• A history of cholelithiasis is not essential for the diagnosis of choledocholithiasis because gallbladder stones can be asymptomatic.
• Pain is the most frequent presenting symptom. The pain is colicky in nature, moderate in severity, and located in the right upper quadrant of the abdomen. The pain is intermittent, transient, and recurrent and may be associated with nausea and vomiting. If the pain is severe, consider a coexisting condition as the primary cause of the pain.
• Jaundice occurs when the CBD becomes obstructed and conjugated bilirubin enters the bloodstream. A history of clay-colored stools and tea-colored urine is obtained from such patients in approximately 50% of cases. The jaundice can be episodic.
• Fever is an indication of cholangitis, and the classic Charcot triad of fever, jaundice, and right upper quadrant pain strongly favors the diagnosis. A recent study on patients with cholangitis showed fever in 92% of patients, jaundice in 65%, pain in 42%, and all 3 in 19%. Cholangitis has a varied presentation, from a mild self-limiting illness to septic shock, observed in 5% of patients.
• Gallstones are responsible for 50% of all cases of pancreatitis. Conversely, 4-8% of patients with gallstones develop pancreatitis. Pancreatitis can be precipitated if CBD obstruction occurs at the level of the ampulla of Vater. Pancreatic pain is different from biliary pain. The pain is located in the epigastric and midabdominal areas and is sharp, severe, continuous, and radiates to the back. Nausea and vomiting are frequently present, and a similar previous episode is reported by approximately 15% patients.
• A history of benign CBD strictures, sclerosing cholangitis, sphincter of Oddi dysfunction, and cystic dilatation of the CBD are important in the diagnosis of secondary biliary stones.
• The presence of parasitic infestation with A lumbricoides or C sinensis may result in the development of primary CBD stones, observed in appropriate populations with the so-called Oriental cholangiohepatitis.

Physical

Specific findings upon physical examination are few and are principally abdominal tenderness and jaundice.

• Tenderness is found in the right upper quadrant of the abdomen. It is moderate in severity, and guarding (voluntary or involuntary) or rebound is absent. Severe tenderness, including the Murphy sign, should suggest the presence of acute cholecystitis, either concomitantly or alone.
• The extent of icterus depends on the severity and duration of CBD obstruction.
• Systemic signs such as fever, hypotension, and flushing may be present and are often indicative of infection, sepsis, or both.

Causes

CBD stones are either primary or secondary. Primary stones arise within the biliary duct system, while secondary stones develop in the gallbladder and migrate to the CBD. In the United States, up to 85% of all CBD stones are secondary in origin.

• Primary CBD stones are caused by conditions leading to bile stasis and chronic bactibilia. Up to 90% of patients with brown pigment CBD stones have bile culture results positive for bacteria. Primary duct stones are usually brown pigment stones. Brown stones differ from black pigment stones by having a higher content of cholesterol. Brown stones are soft and earthy in consistency and take the shape of the duct.
• • In Western populations, biliary stasis is secondary to factors such as sphincter of Oddi dysfunction, benign biliary strictures, sclerosing cholangitis, and cystic dilatation of the bile ducts. Bile stasis promotes growth of bacteria, which produce phospholipase A1, thus releasing fatty acids from biliary phospholipids. The duct epithelium and/or bacteria (eg, Escherichia coli) produce beta-glucuronidase in amounts sufficient to deconjugate bilirubin diglucuronide. The presence of free fatty acids, deconjugated bilirubin, and bile acids leads to the formation of insoluble calcium bilirubinate particles. With the loss of bile acids, cholesterol becomes insoluble, resulting in the formation of biliary sludge. The sludge also contains mucin and bacterial cytoskeletons, which further aid in stone formation.
  • In Asian populations, infestation with A lumbricoides and C sinensis may promote stasis by either blocking the biliary ducts or by damaging the duct walls, resulting in stricture formation. Bactibilia is also common in these instances, probably secondary to episodic portal bacteremia. Some authors have suggested that the stones are formed because of the bactibilia alone and that the parasites' presence is just a coincidence.
• Secondary CBD stones arise from the gallbladder, migrate to the CBD, and have a typical spectrum of cholesterol stones and black pigment stones. Bacteria can be cultured from the surface of cholesterol and pigment stones but not from the core, suggesting that bacteria do not play a role in their formation.
• • The prerequisites for the formation of cholesterol stones are cholesterol supersaturation, stasis, and accelerated nucleation. The sex of the patient, parity, obesity, weight loss, and genetics are risk factors for the development of cholesterol stones.
  • Black pigment stones typically occur in conditions in which bilirubin excretion is increased, as in hemolytic disorders and in situations associated with profound gallbladder stasis such as prolonged fasting and long-term parenteral nutrition. Pigment stones are more common in patients with cirrhosis and ileal disease, although the exact mechanism of stone formation under these conditions is not understood.

DIFFERENTIALS

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Other Problems to be Considered

Sclerosing cholangitis
Cholangiosarcoma

WORKUP

Section 5 of 11  

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Lab Studies

• Laboratory tests are helpful, but results are not specific for the diagnosis of choledocholithiasis. As mentioned earlier, patients with choledocholithiasis are often asymptomatic, and, in such patients, laboratory test results can be completely normal. Finding a laboratory test that can help identify asymptomatic CBD stones and thus reduce the need for invasive testing remains a major diagnostic challenge.
• Patients with cholangitis and pancreatitis have abnormal laboratory test values. Importantly, a single abnormal laboratory value does not confirm the diagnosis of choledocholithiasis, cholangitis, or pancreatitis; rather, a coherent set of laboratory studies leads to the correct diagnosis.
• • WBC count elevations indicate the presence of infection or inflammation, but this finding is nonspecific.
  • Serum bilirubin level elevations indicate obstruction of the CBD; the higher the bilirubin level, the greater the predictive value. CBD stones are present in approximately 60% of patients with serum bilirubin levels greater than 3 mg/dL.
  • Serum amylase and lipase values are elevated in the presence of acute pancreatitis complicating choledocholithiasis.
  • Alkaline phosphatase and gamma-glutamyl transpeptidase levels are elevated in patients with obstructive choledocholithiasis. These test results have a good predictive value for the presence of CBD stones.
  • Prothrombin time may be elevated in patients with prolonged CBD obstruction, secondary to depletion of vitamin K (the absorption of which is bile-dependent).
  • Liver transaminase (serum glutamic-pyruvic transaminase and serum glutamic-oxaloacetic transaminase) levels are elevated in patients with choledocholithiasis complicated by cholangitis, pancreatitis, or both.
  • Blood culture results are positive in 30-60% of patients with cholangitis.

Imaging Studies

• Cholangiography remains the most reliable test for the diagnosis of choledocholithiasis, but its invasive nature, associated morbidity, and cost preclude it from being the screening test of choice. Several diagnostic modalities are available, and these are best divided into preoperative, intraoperative, and postoperative studies. The latter are used for the diagnosis of retained CBD stones.
• Preoperative studies
• • Transabdominal ultrasonography
  • • This is a noninvasive, inexpensive, and readily available modality for assessment of the biliary tree. It is usually the first modality used in the diagnosis of patients with biliary-related symptoms.
    • Ultrasonography findings are accurate in the diagnosis of gallbladder stones (97% in elective situations and 80% in presence of acute cholecystitis), but CBD stones are missed frequently (sensitivity 15-40%). The detection of CBD stones is impeded by the presence of gas in the duodenum, possible reflection and refraction of the sound beam by curvature of the duct, and the location of the duct beyond the optimal focal point of the transducer.
    • On the other hand, CBD dilatation is identified accurately, with up to 90% accuracy.
    • The usefulness of ultrasonography findings as a predictor of CBD stones is at best 15-20%.
  • Endoscopic ultrasonography
  • • This is the introduction of a high-frequency (7.5-12 MHz) ultrasonic probe advanced into the duodenum under endoscopic guidance. A water-filled balloon is used to provide an acoustic window.
    • Sensitivity and specificity of CBD stone detection are reported in range of 85-100%. This is a significant improvement over the transabdominal route.
    • With endoscopic ultrasonography, the advantage of noninvasiveness is lost, cost is increased, and the services of an experienced endoscopist/ultrasonographer are needed.
  • Computed tomography scan
  • • CT scan findings are very accurate in the detection of biliary tree obstruction and ductal dilatation, both intrahepatic and extrahepatic.
    • CT scan has a sensitivity of 75-90% in the detection of CBD stones, which makes it an essential tool in the evaluation of patients with jaundice.
    • It is capable of defining the level of the obstruction and provides information about the surrounding structures, especially the pancreas.
  • Magnetic resonance cholangiopancreatography
  • • This technique provides images derived from different magnetic properties of various tissues. Gadolinium is used as a contrast for this test.
    • It is a noninvasive tool with 97% accuracy, 92% sensitivity, and 100% specificity. It is improving with the advent of new sequences in imaging of the CBD.
    • Cost, inconvenience, and limitations (eg, obesity, presence of metal objects, eg, pacemakers) are some of its disadvantages.
  • Cholangiography
  • • This remains the criterion standard for the detection of CBD stones.
    • In the past, intravenous cholangiography was the only available method for assessing the biliary tree, but the results had poor accuracy and sensitivity, not to mention major concerns with allergic reactions. Intravenous cholangiography became obsolete with the introduction of endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC).
    • ERCP was introduced in the early 1970s and has become the diagnostic and therapeutic tool of choice in patients with choledocholithiasis. The CBD is cannulated through the ampulla, contrast material is injected, and films are obtained. The experience of the endoscopist is the best predictor of success, which is 90-95% in expert hands. Complications are hyperamylasemia and cholangitis. Prophylactic antibiotics are often recommended, especially in patients with CBD obstruction. In most patients, ERCP is the modality of choice when choledocholithiasis is suggested.
    • PTC may be the modality of choice in patients in whom ERCP is difficult (eg, those with previous gastric surgery or distal obstructing CBD stone or the lack of an experienced endoscopist) and in patients with extensive intrahepatic stone disease and cholangiohepatitis. A long large-bore needle is advanced percutaneously and transhepatically into an intrahepatic duct, and cholangiography is performed. A catheter can be placed in the biliary tree over a guidewire. Uncorrected coagulopathy is a contraindication for PTC, and the normal size of the intrahepatic ducts makes the procedure difficult. Prophylactic antibiotics are recommended to reduce the risk of cholangitis.
• Intraoperative studies
• • Intraoperative cholangiography
  • • An area of much debate is the use of routine intraoperative cholangiography (IOC) during a cholecystectomy. This debate has lately gained momentum with the advent of the laparoscopic cholecystectomy.
    • The argument in favor of routine IOC is that it provides accurate information about biliary anatomy and the presence of CBD stones, thus decreasing the incidence of intraoperative bile duct injury.
    • The counterpoint is that the incidence of retained CBD stones is no greater in patients who underwent IOC only when CBD stones were suggested clinically compared with patients in whom it was performed routinely. Also, the risk of bile duct injury is independent of whether an IOC was performed or not. Other drawbacks include the risk and cost of the procedure.
    • IOC is performed by inserting a catheter intraoperatively into the cystic duct, followed by injection of diluted (50%) contrast material to outline the biliary tree. Films are taken and are assessed for the presence of filling defects, the anatomy and caliber of the biliary tree, and the flow of contrast into the duodenum. This procedure can be performed at open or laparoscopic cholecystectomy.
    • IOC findings have a positive predictive value of 60-75% for the detection of CBD stones. The procedure can fail due to (1) inability to cannulate the cystic duct; (2) leakage of contrast during the injection; (3) air bubbles mimicking stones; (4) contrast flowing too quickly into the duodenum, preventing proper filling of the biliary tree; and (5) spasm of the sphincter of Oddi.
  • Intraoperative ultrasonography
  • • Special probes are used to visualize the biliary tree. It can be performed using either open or laparoscopic techniques, and results have a positive predictive value of approximately 75%.
    • With the recent introduction of a small high-frequency probe in a 6F sheath, performing intraluminal ultrasonography is now possible.
    • The reported sensitivity is similar to that of IOC. Operator dependency limits the usefulness of this modality.
• Postoperative studies
• • T-tube cholangiography
  • • Retained CBD stones are identified in 2-10% of patients after CBD exploration. These are most commonly detected upon routine T-tube cholangiography performed 7-10 days postoperatively.
    • T-tubes are placed following CBD exploration to help in the diagnosis and management of retained stones.
    • If no obstruction is identified on the cholangiogram findings, the tube is clamped and left in place for 6 weeks. The cholangiogram is repeated after 6 weeks (small stones may pass spontaneously), and any retained stones are removed percutaneously.
  • ERCP: After a cholecystectomy, ERCP is the modality of choice to aid in the diagnosis and treatment of retained stones that were undetected or were left behind to be dealt with endoscopically.
  • PTC: This is used in patients with retained intrahepatic stones or in patients with gastric surgery, in whom ERCP is more difficult to perform.

Procedures

• Choledochoscopy: Choledochoscopy can be performed using either open or laparoscopic techniques. Small, flexible choledochoscopes are introduced through an open CBD or cystic duct. This enables direct visualization and extraction of CBD stones. Sensitivity for detection approaches 100% in expert hands. Choledochoscopy can be performed postoperatively through the tract of a T-tube 6 weeks after the T-tube was placed.
• Endoscopic sphincterotomy: This procedure can be performed preoperatively or postoperatively for CBD stones. Usually, stones smaller than 1 cm pass spontaneously within a few days of the sphincterotomy. For extraction of larger stones, a basket or a balloon catheter is required. Endoscopic sphincterotomy is contraindicated in patients with coagulopathy and usually in patients with a long distal CBD.

TREATMENT

Section 6 of 11  

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Medical Care

Several different modalities are available for the nonsurgical treatment of choledocholithiasis. The choices include ERCP, percutaneous extraction, and the remote consideration of lithotripsy. The aim of treatment is to extract the stone; however, if this is not possible, the aim is to provide drainage for the obstructed bile in order to improve the patient's condition while waiting for definitive surgical intervention. These procedures can also be performed postoperatively to remove retained stones.

• Endoscopic retrograde cholangiopancreatography
• • ERCP is used initially as a diagnostic procedure. Once the presence of choledocholithiasis is confirmed (initial or retained stones), therapeutic options depend on the size and location of the stone(s).
  • Small stones can be retrieved with a Dormia basket or a Fogarty catheter with an intact papilla. In most situations, a sphincterotomy is needed before the stones can pass spontaneously or be extracted.
  • Stones smaller than 1 cm pass spontaneously within 48 hours. Stones that are 1-2 cm in diameter require extraction with the basket or Fogarty catheter in addition to the sphincterotomy. Stones larger than 2 cm in diameter usually require further treatment; lithotripsy or chemical dissolution (cholesterol stones) with monooctanoin acid via a nasobiliary tube has been considered. If stone extraction is unsuccessful, a biliary drainage procedure, whether internal or external, is performed.
  • The success rate of stone extraction by ERCP in cases of choledocholithiasis is 85-90% in experienced hands. Complications of sphincterotomy and stone extraction occur in 10% of cases. These include bleeding (2%), duodenal perforation (1%), cholangitis (2%), pancreatitis (2%), bile duct injury (<1%), and the usual complications associated with upper GI endoscopy (2%). The mortality rate following endoscopic sphincterotomy is 1%. Endoscopic sphincterotomy is contraindicated in patients with uncorrected coagulopathy.
• Percutaneous extraction
• • This is performed after diagnostic PTC findings have confirmed the presence of CBD stones. An external biliary catheter is placed, and the tract is dilated over several weeks (2-6 wk) up to 16F size by placement of progressively larger catheters. The CBD stones are then extracted using a Dormia basket or a choledochoscope. Stones or their fragments can be trapped inside a basket and passed through the sphincter of Oddi into the duodenum. The procedure may need to be repeated for complete clearance.
  • The morbidity rate is approximately 10%, and the mortality rate is 1%. Complications include bleeding, duct injury, bile leakage, and cholangitis. The success rate is 75-85%. The procedure is contraindicated in patients with coagulopathy.
• Extracorporeal shock wave lithotripsy
• • This procedure has been mainly used as an adjunct to sphincterotomy and a percutaneous approach.
  • It carries a high rate of failure (95%) when used alone and has a high complication rate (19%). Complications include biliary pain (13%), cholangitis (5%), hemobilia (5%), ileus (2.5%), and complications related to procedure itself (13%).
• See related CME at New Guidelines Address Management of Common Bile Duct Stones.

Surgical Care

Surgical treatment may be required for CBD stones that are discovered preoperatively or intraoperatively. Retained stones in the CBD postoperatively are usually dealt with endoscopically or by interventional radiology. If both methods fail, operative management is contemplated. Two issues must be addressed in the surgical treatment of choledocholithiasis, as follows: (1) the exploration of the CBD, and (2) the fate of the gallbladder. Exploration of the CBD should include clearance of the stones and, sometimes, a drainage procedure. Surgical methods used to achieve this goal vary and can be performed by an open or laparoscopic route. The timing and necessity of a cholecystectomy in patients with choledocholithiasis who have asymptomatic gallbladder stones remains a subject of debate.

• Open choledochotomy
• • Traditionally, open choledochotomy has been the standard of care for the treatment of choledocholithiasis. It remains a viable option in situations in which laparoscopy is contraindicated or when laparoscopy has failed. Although this procedure carries a low morbidity and mortality rate in young patients (<1%), the mortality rate is as high as 4% in elderly populations. Moreover, it is associated with greater postoperative pain and discomfort, and a more prolonged recovery period is needed compared to the laparoscopic or endoscopic methods.
  • Choledochotomy is performed by placing 2 traction sutures on either side of the intended choledochotomy incision on the CBD distal to the cystic duct. The anterior wall of the CBD is opened longitudinally for a distance of approximately 1-1.5 cm, while traction is applied to the sutures. Stone forceps, scoops, Fogarty balloon catheters, and irrigating catheters can be used for the removal of stones. A choledochoscope can be used for confirming that the CBD is clear and for removing any retained stones. A Dormia basket can be helpful at this point.
  • Once the CBD is cleared, it is closed over a 16F T-tube using 4-0 monofilament absorbable suture. A closed suction drain is placed in the foramen of Winslow in anticipation of any bile leakage. A T-tube cholangiogram is performed 10-14 days postoperatively, and the T-tube is removed if no retained stones are seen.
  • A small-caliber duct (<6 mm in diameter) is a relative contraindication to choledochotomy.
• Transcystic exploration
• • This technique is used to clear the CBD of stones during laparoscopic cholecystectomy, after choledocholithiasis is confirmed based on findings from IOC. The cystic duct is dissected close to its junction with the CBD, and a transverse incision is made in that area. A soft hydrophilic guidewire is passed into the CBD through the cholangiogram catheter under fluoroscopic guidance. Once the position of the wire in the CBD is confirmed, the cholangiogram catheter is advanced into the CBD.
  • Isotonic sodium chloride solution is used to irrigate the CBD in an attempt to flush small stones through the sphincter of Oddi or out through the opening in the cystic duct. For extraction of larger stones, a Dormia basket is passed over the guidewire into the CBD under fluoroscopic guidance.
  • Throughout the procedure, constant flushing with isotonic sodium chloride solution is performed. At the end of the procedure, IOC is repeated to ensure that all the stones have been removed.
  • If the cystic duct is large enough or can be balloon-dilated, a flexible choledochoscope can be passed and the CBD examined under direct vision. The CBD is kept inflated with isotonic sodium chloride solution for better visualization. Intraluminal stones can be extracted with a basket under direct vision using the working port of the scope.
  • In the case of large impacted stones (>8 mm), intracorporeal lithotripsy can be used. This procedure employs either pulse-dye laser or electrohydraulic pulses that cause fragmentation of the stone. The smaller fragments are treated as described in Medical Care. Clear visualization of the stone is required in order to avoid misdirecting the energy of the probe and causing CBD injury. Due to the high cost and the fact that most CBD stones can be managed successfully without the use of intracorporeal lithotripsy, few centers have gained sufficient experience with this technique.
  • Balloon dilatation of the sphincter of Oddi can be performed when all other techniques have failed to clear the stones. A risk exists for mild pancreatitis (3% in one series). This procedure should be avoided in patients with a diagnosis of biliary dyskinesia, pancreatitis, and sphincter anomalies. It is indicated in the presence of small ducts, for which the risk of CBD stricture after choledochotomy is high. In one small series of 20 patients, the success rate was 80%.
  • Antegrade sphincterotomy can be performed; the morbidity rate is low and the success rate is 100% as reported recently in a series of 22 patients. The success rate for the transcystic approach is 80-95%.
• Drainage procedures (transduodenal sphincteroplasty choledochoduodenostomy, choledochojejunostomy)
• • Transduodenal sphincteroplasty entails a retrograde approach to the exploration and clearance of the CBD.
  • • During open surgery and after cholecystectomy has been completed, a Fogarty balloon catheter is passed through the cystic duct into the CBD and through the sphincter of Oddi. The duodenum is then mobilized by performing the Kocher maneuver. The ampulla is identified by palpating the balloon catheter, and a small transverse duodenotomy is performed on the anterior duodenal wall just above the ampulla.
    • A sphincterotomy is performed at the 11-o'clock mark (to avoid the pancreatic duct, which is located between the 4- and 5-o'clock positions). The sphincterotomy is carried for a distance of approximately 1 cm. The edges of the incision are sutured at the beginning of the incision and at its apex using an absorbable suture. The balloon catheter is withdrawn from the cystic duct and inserted through the ampulla in a retrograde fashion to extract the stones. A choledochoscope can also be used.
    • After the duodenotomy is closed in a transverse fashion, a completion cholangiogram is performed through the cystic duct. The cystic duct stump is closed.
    • The advantages of this procedure are that (1) it avoids a choledochotomy, (2) it is good for small-caliber CBDs, and (3) it facilitates drainage. The drawbacks are that it requires open surgery and opening of the duodenum. The success rate in an earlier series was reported as 90-100%, with morbidity and mortality rates slightly better than that with open choledochotomy. No biliary strictures were reported.
    • Approximately 30% of all patients requiring an open choledochotomy need a drainage procedure. Indications for a drainage procedure are multiple CBD stones (>4), sphincter of Oddi stenosis or dysfunction, primary CBD stones, previous choledocholithotomy, and marked CBD dilatation.
  • Choledochoduodenostomy is the most commonly employed drainage procedure and can be performed either side-to-side or end-to-side. In the side-to-side procedure, sump syndrome is a feared complication, in which food particles reflux into the CBD, resulting in obstruction, cholangitis, and/or pancreatitis. This complication can be diminished if the size of the anastomosis is limited to 14 mm.
  • Choledochojejunostomy is performed either in continuity or preferably as a Roux-en-Y loop that is passed in a retrocolic fashion. The preferred anastomotic size is 2.5 cm. It has the disadvantage of an added anastomotic line, but an advantage is that it is not associated with reflux of food particles.
• Cholecystectomy
• • Performance of a cholecystectomy in patients with choledocholithiasis remains controversial, although most experts recommend it. However, in patients who cannot tolerate surgery well (eg, due to age, medical problems), leaving the gallbladder in situ is an option as long as the organ is asymptomatic.
  • Cholecystectomy is not indicated for primary CBD stones.

Consultations

Management of choledocholithiasis is a multidisciplinary affair and requires the expertise of various medical specialists.

• Obviously, the gastroenterologist/endoscopist and the general/laparoscopic surgeon are the key players.
• An interventional radiologist is needed for both diagnosis and treatment at times, and the services of an infectious disease specialist are required in patients with cholangitis.
• In case lithotripsy is considered, the services of a clinician with experience in this rarely performed procedure are necessary.

Diet

Patients with choledocholithiasis are instructed to not take anything by mouth on the day of the procedures. No special diet is required either before or after the procedure.

MEDICATION

Section 7 of 11  

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Medications are used as an adjunct in the management of choledocholithiasis. See In/Out Patient Meds.

Drug Category: Antibiotics

Need for prophylaxis and therapy depends on the patient's clinical presentation.

Drug Category: Gastrointestinal agents

Used for stress ulcer prophylaxis.

Drug Category: Histamine-2 receptor antagonists

Reversible competitive blockers of H2 receptors, particularly those in the gastric parietal cells, where they inhibit acid secretion. H2 antagonists are highly selective, do not affect H1 receptors, and are not anticholinergic agents.

Drug Category: Anticoagulants

Used for DVT prophylaxis.

Drug Category: Proton pump inhibitors

Indicated for peptic ulcer disease. Indicated for prophylaxis against stress ulcerations in setting of choledocholithiasis. Should be reserved for patients with known peptic ulcer disease.

FOLLOW-UP

Section 8 of 11  

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Further Inpatient Care

• Tube cholangiography: Whenever a tube or biliary drain is placed (eg, surgically, percutaneously, or radiologically), a follow-up cholangiogram through the tube is recommended. A tube cholangiogram helps assess for the presence of retained stones, the status of the sphincter of Oddi, the architecture of the biliary tree, and the condition of the anastomosis. This study is best performed under fluoroscopic guidance in the radiology department.
• Laboratory data: Serum bilirubin levels and liver enzymes are measured in the postprocedure period as part of follow-up care.

Further Outpatient Care

• Laboratory data: Serum bilirubin levels and liver enzymes are measured in the postprocedure period as follow-up care.
• Management of retained stones: Extraction (or consideration of lithotripsy) of retained stones is performed 6 weeks after placement of a biliary drain or catheter, when the tract is mature. Dissolution of the stones using monooctanoin is another option.

In/Out Patient Meds

• Antibiotics
• • Antibiotics are needed for prophylaxis or for acute infection, depending on the patient's presentation. In the absence of biliary infection and in the setting of a procedure that results in manipulation of the biliary tree, antibiotic prophylaxis may be indicated. Single-drug therapy with a broad-spectrum antibiotic is preferable. The newer penicillins (piperacillin, mezlocillin), with or without beta-lactamase inhibitor, are effective because of their broad coverage. This is also true of some of the third-generation cephalosporins.
  • Administer the antibiotics intravenously immediately before the procedure and discontinue them at the end of the procedure, unless a prosthesis or a drain is inserted. In the setting of cholangitis, antibiotics are used therapeutically. Traditionally, ampicillin was used in combination with an aminoglycoside and metronidazole as a broad-spectrum regimen for empirical treatment until specific culture and sensitivity results were obtained. However, as mentioned above, the broad-spectrum newer penicillins or third-generation cephalosporins, with or without beta-lactamase inhibitors, are good choices. Antibiotics are customized after obtaining culture results. In mild cases, antibiotics can be administered at home either orally or intravenously.
• Stress ulcer prophylaxis: This is achieved by using sucralfate, H2 antagonists, or proton pump inhibitors.
• Deep venous thrombosis prophylaxis: A mini dose of heparin (5000 U SC q12h) or low molecular weight heparin can be used in conjunction with sequential compression pneumatic stockings. Early ambulation remains the best preventative approach.

Transfer

• The patient should be transferred to a center capable of handling this problem. Specialists in the fields mentioned in Consultations should be available, and the center should be equipped with the diagnostic and therapeutic modalities necessary for the job at hand.

Complications

• Cholangitis
• Gallstone pancreatitis
• Liver failure and cirrhosis
• Sepsis
• Renal failure
• Respiratory insufficiency
• Retained and impacted stones
• Biliary duct injury
• Hepatic vascular injury

Prognosis

• Prognosis of choledocholithiasis depends on the presence and severity of complications. Of all patients who refuse surgery or are unfit to undergo surgery, 45% remain asymptomatic from choledocholithiasis, while 55% experience varying degrees of complications.

Patient Education

• For excellent patient education resources, visit eMedicine's Liver, Gallbladder, and Pancreas Center and Cholesterol Center. Also, see eMedicine's patient education article Gallstones.

MISCELLANEOUS

Section 9 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical/Legal Pitfalls

• Medicolegal concerns in the management of choledocholithiasis are multifaceted. They relate to the diagnosis, management, and follow-up because of the complexity of the issue. Maintaining the standard of care and obtaining the appropriate consultations help mitigate medicolegal concerns.

MULTIMEDIA

Section 10 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Media file 1:  Intraoperative cholangiogram demonstrating a distal common bile duct stone with dilatation.
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Media type:  X-RAY

Media file 2:  Postendoscopic sphincterotomy and stone removal x-ray film for same patient as in Media file 1.
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Media type:  X-RAY

Media file 3:  Intraoperative cholangiogram demonstrating a distal common bile duct stone without dilatation.
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Media type:  X-RAY

Media file 4:  Postendoscopic sphincterotomy and stone removal x-ray film for same patient as in Media file 3.
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Media type:  X-RAY

Media file 5:  Magnetic resonance cholangiopancreatography (MRCP) depicting common bile duct and common hepatic duct full of stones.
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Media type:  MRI

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

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