Choledocholithiasis: Difference between revisions
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==Background== | ==Background== <!--T:1--> | ||
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*Occurs when stone expelled from gallbladder becomes impacted in the common bile duct | *Occurs when stone expelled from gallbladder becomes impacted in the common bile duct | ||
*If infected, becomes [[Special:MyLanguage/Cholangitis|Cholangitis]] | *If infected, becomes [[Special:MyLanguage/Cholangitis|Cholangitis]] | ||
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==Clinical Features== | ==Clinical Features== <!--T:3--> | ||
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*[[Special:MyLanguage/RUQ pain|RUQ pain]] | *[[Special:MyLanguage/RUQ pain|RUQ pain]] | ||
**Radiation to the right shoulder (phrenic nerve irritation) | **Radiation to the right shoulder (phrenic nerve irritation) | ||
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==Differential Diagnosis== | ==Differential Diagnosis== <!--T:5--> | ||
===[[Special:MyLanguage/Right upper quadrant abdominal pain|RUQ Pain]]=== | ===[[Special:MyLanguage/Right upper quadrant abdominal pain|RUQ Pain]]=== <!--T:6--> | ||
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*[[Special:MyLanguage/Gallbladder Disease (Main)|Gallbladder disease]] | *[[Special:MyLanguage/Gallbladder Disease (Main)|Gallbladder disease]] | ||
**[[Special:MyLanguage/Acute cholecystitis|Acute cholecystitis]] | **[[Special:MyLanguage/Acute cholecystitis|Acute cholecystitis]] | ||
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==Evaluation== | ==Evaluation== <!--T:8--> | ||
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[[File:Ultrasonography of common bile duct stone, with arrow.jpg|thumb|RUQ ultrasound showing non-obstructing common bile duct stone.]] | [[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 | *[[Special:MyLanguage/LFTs|LFTs]], lipase, and basic chemistry | ||
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==Management== | ==Management== <!--T:10--> | ||
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*[[Special:MyLanguage/Pain control|Pain control]] | *[[Special:MyLanguage/Pain control|Pain control]] | ||
*[[Special:MyLanguage/Fluid resuscitation|Fluid resuscitation]] and [[Special:MyLanguage/electrolyte repletion|electrolyte repletion]] | *[[Special:MyLanguage/Fluid resuscitation|Fluid resuscitation]] and [[Special:MyLanguage/electrolyte repletion|electrolyte repletion]] | ||
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==Disposition== | ==Disposition== <!--T:12--> | ||
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*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 | ||
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==See Also== | ==See Also== <!--T:14--> | ||
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*[[Special:MyLanguage/Gallbladder disease (main)|Gallbladder disease (main)]] | *[[Special:MyLanguage/Gallbladder disease (main)|Gallbladder disease (main)]] | ||
==External Links== | ==External Links== <!--T:16--> | ||
==References== | ==References== <!--T:17--> | ||
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<references/> | <references/> | ||
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[[Category:GI]] | [[Category:GI]] | ||
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Latest revision as of 12:30, 7 January 2026
Background
- Occurs when stone expelled from gallbladder becomes impacted in the common bile duct
- If infected, becomes Cholangitis
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.
Gallbladder disease types
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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.
- Symptomatic cholelithiasis (biliary colic)
- Choledocholithiasis
- Acute calculous cholecystitis
- Ascending cholangitis
- Acalculous cholecystitis
- Biliary atresia
- Cholestasis of pregnancy
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
- Gallbladder disease
- 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
- 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
- RUQ Ultrasound
Management
- Pain control
- Fluid resuscitation and electrolyte repletion
- NPO
- If any concern for concomitant acute cholecystitis, start antibiotics
- Always consider cholangitis
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
- ↑ 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.