Choledocholithiasis

Rowena Almeida, M.D.
Talia Zenlea, M.D.

Definition

Choledocholithiasis is a derivation from the Greek words of choli (bile), docheion (container), and lithos (stone) and refers to the presence of gallstones within the common bile duct (CBD).

Synonyms

Common bile duct stone(s)

ICD-10CM CODES
K80.50	Calculus of bile duct

Epidemiology & Demographics

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While the exact incidence and prevalence are unknown, an estimated 10% to 20% of patients are found to have choledocholithiasis at the time of cholecystectomy.
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Passage of gallstones into the CBD occurs in approximately 10% to 15% of those with cholelithiasis, and the incidence is known to increase with age. Approximately 95% of those with choledocholithiasis will also have cholelithiasis.
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Risk factors for gallstone formation include nonmodifiable factors such age, female sex, family history, ethnic background, and genetic predilection, while modifiable factors are centripetal obesity and metabolic syndrome, rapid weight loss, ileal Crohn’s disease, cirrhosis, total parenteral nutrition, and medications such as estrogen replacement therapy.

Physical Findings & Clinical Presentation

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Uncomplicated choledocholithiasis presents with biliary colic; it is classically described as intense and constant pain in the right upper quadrant or epigastric region, associated with nausea and vomiting.
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Occasionally patients may remain asymptomatic, but resolution of pain more often reflects passage of stone into the bowel.
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Physical examination demonstrates right upper quadrant or epigastric tenderness and occasionally jaundice.
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Courvoisier’s sign for a palpable gallbladder is more typically associated with malignant obstruction of the CBD, but it has been reported with choledocholithiasis.
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Other clinical findings of fever (Charcot’s triad), hypotension, and altered mental status (Reynolds’ pentad) are found only when choledocholithiasis is complicated by acute cholangitis.
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Choledocholithiasis can also be complicated by acute pancreatitis.

Etiology

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The majority of cases are due to passage of cholesterol stones from the gallbladder into the common bile duct.
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De novo formation of choledocholithiasis (primary choledocholithiasis) is uncommon but is seen among those with increased propensity for pigment stone formation due to chronic recurrent pyogenic cholangitis from trematodes, congenital biliary duct anomalies, dilated or strictured ducts or MDR3 gene defects causing impairments in biliary phospholipid secretions, or biliary stasis such as from cystic fibrosis.
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Brown pigment stones comprise the majority of pigment stones in the bile duct, often found proximal to biliary stricture and associated with cholangitis.

Diagnosis

Differential Diagnosis

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Biliary pain
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Acute cholecystitis
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Sphincter of Oddi dysfunction
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Functional gallbladder disorder
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Malignant obstruction
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Choledochal cyst
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Papillary stenosis
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AIDS-associated cholangiopathy

Workup

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The constellation of symptomatic cholelithiasis with elevated liver enzymes should prompt a transabdominal ultrasound (US) of the right upper quadrant to evaluate for a stone in the CBD, which is the most reliable predictor of choledocholithiasis.
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Elevated liver enzymes are 94% sensitive in detecting choledocholithiasis.
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Clinical predictors may be utilized to risk-stratify patients and to inform the next step in management. For instance, strong predictors for high-risk choledocholithiasis are a CBD stone or dilated CBD seen on transabdominal US, clinical or biochemical evidence of cholangitis, and elevated bilirubin (>1.8 mg/dl).
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See Fig. 1 for the ASGE guideline for a proposed risk stratification model.

FIG.1

Algorithm for the management of patients with symptomatic cholelithiasis.

Adapted from Tse et al. and ASGE 2010

Laboratory Tests

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Elevations in serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) reflect early biliary obstruction, followed by a disproportionate increase in serum bilirubin, alkaline phosphatase (ALP), and gamma-glutamyl transpeptidase (GGT), which are independent predictors of a CBD stone.
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Elevation in ALP is rapid and precedes the rise in bilirubin level, the latter being proportional to the degree of obstruction.
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An isolated and transient increase in alanine transaminase or amylase reflects passage of the gallstone.
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In addition, patients with choledocholithiasis complicated by acute pancreatitis and cholangitis have elevated serum amylase or lipase (>3 times upper limit of normal) and leukocytosis, respectively.

Imaging Studies

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Ultrasound of the gallbladder has a relatively poor sensitivity (22%-55%) for stone detection but is relied on for CBD dilation, which is associated with choledocholithiasis.
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The finding of CBD dilation >8 mm (sensitivity 77%-87%, negative predictive value 95%-96%) with an intact gallbladder is indicative of biliary obstruction. Multiple small gallbladder stones (<5 mm) portend a fourfold higher risk of passage of stones into the CBD.
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Other imaging modalities such as helical CT (Fig. 2), magnetic resonance cholangiopancreatography, CT cholangiography, and endoscopic ultrasound have improved performance characteristics for CBD stone detection; however, their use as first-line diagnostic tools is contingent on diagnostic uncertainty, patient factors, and availability.

FIG.2

A 70-year-old man with choledocholithiasis and a hepatic abscess.

Axial (A) and coronal (B) portal venous phase computed tomography images demonstrate large bile duct stones (arrows) with a focal intrahepatic fluid collection (arrowheads) consistent with the patient’s known pyogenic abscess.

From Soto JA, Lucey BC: Emergency radiology: the requisites, ed 2, Philadelphia, 2017, Elsevier.
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Magnetic resonance cholangiopancreatography should be considered in intermediate-risk patients or in those with prior cholecystectomy.
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High-risk patients should proceed directly to endoscopic retrograde cholangiopancreatography (ERCP) for diagnosis and treatment.

Treatment

Acute General Rx

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Presence of choledocholithiasis warrants treatment.
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The mainstay is removal of CBD stones via ERCP and papillotomy either before or at the time of laparoscopic or open cholecystectomy.
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Failure of ERCP to clear the biliary duct warrants biliary stenting for drainage as a temporary measure in the event of acute cholangitis.
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ERCP without subsequent cholecystectomy may be performed in select high-risk patients, but 10% of these patients will require a subsequent cholecystectomy for recurrence.

Chronic Rx

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Patients with recurrent choledocholithiasis from cholesterol gallstones after cholecystectomy might be considered for chronic treatment with ursodeoxycholic acid to facilitate reduction of cholesterol saturation of bile.

Referral

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Gastroenterology
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General surgery

Ferri – Choledocholithiasis