Choledocholithiasis: Difference between revisions
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==Background==
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*Choledocholithiasis occurs when a stone is expelled out of the gallbladder and becomes impacted in the common bile duct
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==Background== <!--T:1-->


The biliary system includes the hepatic bile canaliculi, intrahepatic ducts, extrahepatic ducts, the gall bladder, the cystic duct, and the common bile duct. The liver produces bile, which is not only a byproduct of red blood cell breakdown, but also aids in digestion. The gallbladder stores bile until stimulated, upon which bile flows out the gallbladder, down the cystic duct into the common bile duct, and ultimately into the 1st portion of the duodenum.
<!--T:2-->
*Occurs when stone expelled from gallbladder becomes impacted in the common bile duct
*If infected, becomes [[Special:MyLanguage/Cholangitis|Cholangitis]]


*Gallstones are classified as cholesterol stones and pigmented stones (black and brown), and are present in approx 20% of females and 8% of males in the United States
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*These stones cause the majority of all biliary tract problems, and depending on where the stone become impacted, specific problems occur.
{{Gallbladder background}}
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{{Gallbladder disease types}}
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==Clinical Features==
 
*[[RUQ pain]]
==Clinical Features== <!--T:3-->
**Radiation to the Right shoulder (phrenic nerve irritation)
 
**Early pain characterized as colicky (intermittent, comes and goes)
<!--T:4-->
*[[Special:MyLanguage/RUQ pain|RUQ pain]]
**Radiation to the right shoulder (phrenic nerve irritation)
**Early pain characterized as colicky, intermittent
**Once impacted, is constant and severe
**Once impacted, is constant and severe
*[[Nausea and Vomiting]]
*[[Special:MyLanguage/Nausea and Vomiting|Nausea and Vomiting]]
*[[Jaundice]]/scleral icterus  
*[[Special:MyLanguage/Jaundice|Jaundice]]/scleral icterus  
**Caused by build up of direct bilirubin in blood
**Caused by buildup of direct bilirubin in blood


==Differential Diagnosis==
===[[Right upper quadrant abdominal pain|RUQ Pain]]===
*[[Gallbladder Disease (Main)|Gallbladder disease]]
**[[Acute cholecystitis]]
**[[Cholangitis]]
**[[Symptomatic cholelithiasis]]/[[Biliary Colic]]
**[[Acalculous cholecystitis]]
**[[Gallstone pancreatitis]]
**[[Choledocholithiasis]]
*[[Peptic ulcer disease]] with or without perforation
*[[Pancreatitis]]
*[[Acute hepatitis]]
*[[Pyelonephritis]]
*[[Pneumonia]]
*[[Kidney stone]]
*[[GERD]]
*[[Appendicitis]] (retrocecal)
*[[Pyogenic liver abscess]]
*[[Fitz-Hugh-Curtis Syndrome]]
*Hepatomegaly due to [[CHF]]
*[[Herpes zoster]]
*[[Myocardial ischemia]]
*[[Bowel obstruction]]
*[[Pulmonary embolism]]
*[[Abdominal aortic aneurysm]]


==Evaluation==
==Differential Diagnosis== <!--T:5-->
Labs
*Particularly LFTs, Lipase, and Basic Chemistry
Imaging
*Ultrasound of RUQ
**Noninvasive and quick
**Common bile duct < 4 mm plus 1mm per decade after 40 yrs old
**While UTZ is highly sensitive and specific for [[acute cholecystitis]], it lacks this in identifying cholelithiasis secondary to exam limitations (i.e. difficulty identifying the CBD)
*ERCP - highly sensitive and specific, also therapeutic
*MRCP - comparable to ERCP in Sn/Sp
*HIDA Scan - not useful, as IDA (technetium 99m-labeled iminodiacetic acid) can still go into gallbladder


==Management==
 
*Pain relief
===[[Special:MyLanguage/Right upper quadrant abdominal pain|RUQ Pain]]=== <!--T:6-->
*Fluid and electrolyte repletion
 
<!--T:7-->
*[[Special:MyLanguage/Gallbladder Disease (Main)|Gallbladder disease]]
**[[Special:MyLanguage/Acute cholecystitis|Acute cholecystitis]]
**[[Special:MyLanguage/Cholangitis|Cholangitis]]
**[[Special:MyLanguage/Symptomatic cholelithiasis|Symptomatic cholelithiasis]]/[[Special:MyLanguage/Biliary Colic|Biliary Colic]]
**[[Special:MyLanguage/Acalculous cholecystitis|Acalculous cholecystitis]]
**[[Special:MyLanguage/Gallstone pancreatitis|Gallstone pancreatitis]]
**[[Special:MyLanguage/Choledocholithiasis|Choledocholithiasis]]
*[[Special:MyLanguage/Peptic ulcer disease|Peptic ulcer disease]] with or without perforation
*[[Special:MyLanguage/Pancreatitis|Pancreatitis]]
*[[Special:MyLanguage/Acute hepatitis|Acute hepatitis]]
*[[Special:MyLanguage/Pyelonephritis|Pyelonephritis]]
*[[Special:MyLanguage/Pneumonia|Pneumonia]]
*[[Special:MyLanguage/Kidney stone|Kidney stone]]
*[[Special:MyLanguage/GERD|GERD]]
*[[Special:MyLanguage/Appendicitis|Appendicitis]] (retrocecal)
*[[Special:MyLanguage/Pyogenic liver abscess|Pyogenic liver abscess]]
*[[Special:MyLanguage/Fitz-Hugh-Curtis Syndrome|Fitz-Hugh-Curtis Syndrome]]
*Hepatomegaly due to [[Special:MyLanguage/CHF|CHF]]
*[[Special:MyLanguage/Herpes zoster|Herpes zoster]]
*[[Special:MyLanguage/Myocardial ischemia|Myocardial ischemia]]
*[[Special:MyLanguage/Bowel obstruction|Bowel obstruction]]
*[[Special:MyLanguage/Pulmonary embolism|Pulmonary embolism]]
*[[Special:MyLanguage/Abdominal aortic aneurysm|Abdominal aortic aneurysm]]
 
 
==Evaluation== <!--T:8-->
 
<!--T:9-->
[[File:Ultrasonography of common bile duct stone, with arrow.jpg|thumb|RUQ ultrasound showing non-obstructing common bile duct stone.]]
*[[Special:MyLanguage/LFTs|LFTs]], lipase, and basic chemistry
*Imaging
**[[Special:MyLanguage/RUQ Ultrasound|RUQ Ultrasound]]
***Noninvasive and quick
***Common bile duct < 6 mm plus 1mm per decade after 60 yrs old
***US is highly sensitive and specific for [[Special:MyLanguage/acute cholecystitis|acute cholecystitis]], much less sensitive/specific in identifying cholelithiasis due to exam limitations (i.e. difficulty identifying the CBD)
**ERCP - highly sensitive and specific, also therapeutic
**MRCP - comparable sensitivity/specificity to ERCP
**HIDA Scan - not useful, as IDA (technetium 99m-labeled iminodiacetic acid) can still go into gallbladder
 
 
==Management== <!--T:10-->
 
<!--T:11-->
*[[Special:MyLanguage/Pain control|Pain control]]
*[[Special:MyLanguage/Fluid resuscitation|Fluid resuscitation]] and [[Special:MyLanguage/electrolyte repletion|electrolyte repletion]]
*NPO
*NPO
*If any concern for concomitant acute cholecystitis, start antibiotics
*If any concern for concomitant [[Special:MyLanguage/acute cholecystitis|acute cholecystitis]], start antibiotics
**Always consider [[Cholangitis]]
**Always consider [[Special:MyLanguage/cholangitis|cholangitis]]
 
 
==Disposition== <!--T:12-->


==Disposition==
<!--T:13-->
*Admission to medical services
*Admission to medical services
**Consult to GI for spherincerotomy and stone removal vs General Surgery for operative management
**Consult to GI for spherincerotomy and stone removal vs General Surgery for operative management
**Strong predictors for choledocholithiasis on ERCP<ref>Magalhaes J et al. Endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis: From guidelines to clinical practice. Feb 2015. World J Gastrointest Endosc. 2015 Feb 16; 7(2): 128–134.</ref>:
***Clinical ascending [[Special:MyLanguage/cholangitis|cholangitis]]
***CBD stones on US
***Total bilirubin > 4 mg/dL
==See Also== <!--T:14-->
<!--T:15-->
*[[Special:MyLanguage/Gallbladder disease (main)|Gallbladder disease (main)]]
==External Links== <!--T:16-->


==See Also==
*[[Gallbladder disease (main)]]


==External Links==
==References== <!--T:17-->


==References==
<!--T:18-->
<references/>
<references/>


<!--T:19-->
[[Category:GI]]
[[Category:GI]]
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Latest revision as of 12:30, 7 January 2026

Other languages:

Background

  • Occurs when stone expelled from gallbladder becomes impacted in the common bile duct
  • If infected, becomes Cholangitis
Other languages:

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Anatomy & Pathophysiology

  • Gallstones are classified as cholesterol stones and pigmented stones (black and brown), and are present in approx 20% of females and 8% of males in the United States
  • These stones cause the majority of all biliary tract problems, and depending on where the stone become impacted, specific problems occur.
  • Bile flows out the gallbladder, down the cystic duct into the common bile duct, and ultimately into the 1st portion of the duodenum.

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Gallbladder disease types

Gallbladder anatomy (overview).
Gallbladder anatomy
Bile duct and pancreas anatomy. 1. Bile ducts: 2. Intrahepatic bile ducts; 3. Left and right hepatic ducts; 4. Common hepatic duct; 5. Cystic duct; 6. Common bile duct; 7. Sphincter of Oddi; 8. Major duodenal papilla; 9. Gallbladder; 10-11. Right and left lobes of liver; 12. Spleen; 13. Esophagus; 14. Stomach; 15. Pancreas: 16. Accessory pancreatic duct; 17. Pancreatic duct; 18. Small intestine; 19. Duodenum; 20. Jejunum; 21-22: Right and left kidneys.


Clinical Features

  • RUQ pain
    • Radiation to the right shoulder (phrenic nerve irritation)
    • Early pain characterized as colicky, intermittent
    • Once impacted, is constant and severe
  • Nausea and Vomiting
  • Jaundice/scleral icterus
    • Caused by buildup of direct bilirubin in blood


Differential Diagnosis

RUQ Pain


Evaluation

RUQ ultrasound showing non-obstructing common bile duct stone.
  • LFTs, lipase, and basic chemistry
  • Imaging
    • RUQ Ultrasound
      • Noninvasive and quick
      • Common bile duct < 6 mm plus 1mm per decade after 60 yrs old
      • US is highly sensitive and specific for acute cholecystitis, much less sensitive/specific in identifying cholelithiasis due to exam limitations (i.e. difficulty identifying the CBD)
    • ERCP - highly sensitive and specific, also therapeutic
    • MRCP - comparable sensitivity/specificity to ERCP
    • HIDA Scan - not useful, as IDA (technetium 99m-labeled iminodiacetic acid) can still go into gallbladder


Management


Disposition

  • Admission to medical services
    • Consult to GI for spherincerotomy and stone removal vs General Surgery for operative management
    • Strong predictors for choledocholithiasis on ERCP[1]:
      • Clinical ascending cholangitis
      • CBD stones on US
      • Total bilirubin > 4 mg/dL


See Also


External Links

References

  1. ↑ Magalhaes J et al. Endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis: From guidelines to clinical practice. Feb 2015. World J Gastrointest Endosc. 2015 Feb 16; 7(2): 128–134.
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