Choledocholithiasis

Background

• Choledocholithiasis occurs when a stone is expelled out of the gallbladder and becomes impacted in the common bile duct
• If infected, becomes Cholangitis

Clinical Features

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

Differential Diagnosis

RUQ Pain

• 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

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
• Fluid 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

See Also

• Gallbladder disease (main)