Choledocholithiasis

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Background

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

Anatomy & Pathophysiology

Gallbladder anatomy
  • 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

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

  • LFTs, lipase, and basic chemistry
  • Imaging
    • RUQ Ultrasound
      • Noninvasive and quick
      • Common bile duct < 4 mm plus 1mm per decade after 40 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

See Also

External Links

References