BASICS
DESCRIPTION
- Stones in common bile duct (CBD)
- Several types: cholesterol (majority), calcium bilirubinate or pigment, and mixed stones
- System(s) affected: gastrointestinal; hepatobiliary
- Synonym(s): CBD stones; CBD calculi
EPIDEMIOLOGY
Incidence
- Gallstones affect more than 20 million in United States.
- Choledocholithiasis is noted in 7-12% of patients undergoing cholecystectomy for symptomatic gallstones (1) and 18-33% of patients with acute biliary pancreatitis (2).
- Increases with age (30-50% of patients >60 years with gallstones have choledocholithiasis)
- Incidence of gallstones in U.S. adults is 10-20%, rising to 40% in patients over 60 years old.
- Internationally, parasitic infections (e.g., Ascaris lumbricoides) contribute to incidence.
Prevalence
- Gallstone disease in general population = 6-15% (3)
- Predominant sex: female > male
ETIOLOGY AND PATHOPHYSIOLOGY
- CBD stones may be primary or secondary.
- Primary stones form within the biliary tract due to any condition leading to bile stasis or chronic bactibilia
- Secondary stones (more common) form within the gallbladder
- Migrate from the gallbladder to the biliary tree.
- Chronic hemolytic states increase gallstone risk.
- Formation of de novo pigment stones can result from:
- Dilated, sclerosed, or strictured ducts (e.g., recurrent cholangitis)
- Hepatobiliary parasitism
Genetics
- MDR3 defects may predispose to biliary sludge, cholelithiasis, cholestasis of pregnancy, and subsequent choledocholithiasis.
- Increased prevalence in Hispanics
- Hepatobiliary cholesterol hemitransporter ABCG8 variant p.D19H doubles the odds of gallstone recurrence after cholecystectomy (4)[B].
RISK FACTORS
- Cholelithiasis
- Pancreatitis (30%)
- Obesity
- High consumption of long-chain saturated fatty acids
- Chronic hemolysis
- Chronic estrogen exposure
- Rapid weight loss (>25% of original weight, especially after bariatric surgery)
- Prior cholecystectomy:
- <2 years prior: considered a "retained" stone
- >2 years prior: considered "recurrent" stone
GENERAL PREVENTION
Maintain healthy weight and lifestyle. Avoid rapid loss of excess weight.
COMMONLY ASSOCIATED CONDITIONS
- Cholelithiasis, cholecystitis, cholangitis
- Gallstone pancreatitis
DIAGNOSIS
HISTORY
- Asymptomatic (30-50%)
- Right upper quadrant (RUQ) pain:
- Moderate/intense spasmodic pain, often intermittent, transient, recurrent (biliary colic)
- May radiate to right shoulder/back, not relieved by antacids
- Occurs after meals, especially fatty, greasy foods
- Secondary effects of obstruction:
- Nausea/vomiting
- Jaundice/pruritus
- Clay-colored stool
- Tea-colored urine
- Pancreatitis (pain radiating to back)
- Assess for infection (may progress to cholangitis and septic shock):
- Fever, chills, orthostasis, signs of inadequate organ perfusion
- History of CBD strictures, recurrent sclerosing cholangitis, sphincter of Oddi dysfunction, cholelithiasis
- History of rapid loss of >25% of excess weight after gastric bypass
PHYSICAL EXAM
- Fever, hypotension, tachycardia
- Moderate RUQ tenderness on palpation (Murphy sign); palpable gallbladder (less common)
- Jaundice
- Fever, RUQ pain, and jaundice (Charcot triad) + shock and altered mental status (Reynolds pentad) suggest cholangitis.
- Rebound tenderness or guarding often absent
DIFFERENTIAL DIAGNOSIS
Cholangitis (acute or primary sclerosing), cholangiocarcinoma, sphincter of Oddi dysfunction, biliary parasites, papillary stenosis, biliary stricture, narrowed biliary-enteric anastomosis
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
- Labs:
- Liver function tests often show obstructive pattern, elevated total bilirubin, alkaline phosphatase, gamma-glutamyl-transpeptidase (5)
- Alkaline phosphatase >125 IU/L-92% sensitivity, 79% specificity (5)
- Normal liver tests have high negative predictive value (2)[A].
- Probability of choledocholithiasis is high (>50%) if (2)[A]:
- Presence of: gallstones on ultrasound, clinical signs of ascending cholangitis, or total bilirubin >4 mg/dL
- Presence of both dilated CBD (>6 mm with gallbladder in situ) and total bilirubin between 1.8 and 4 mg/dL
- Imaging: most effective to confirm choledocholithiasis
- Transabdominal ultrasound (US):
- Can detect CBD dilatation (sensitivity 77-87%) (2)[A]; less reliable for detecting CBD stones (sensitivity 73%, specificity 91%) (5)
- NPV of normal CBD = 95-96% (4)
- Endoscopic US:
- Sensitivity 95% and specificity 97% (3). Highly sensitive even for smaller stones (2)
- More invasive; higher cost
- Magnetic resonance cholangiopancreatography (MRCP):
- Sensitivity 93%, specificity 96% (may miss stones <5 mm) (2)[A],(3)
- Most accurate noninvasive test; no contrast required
- Preferred over endoscopic retrograde cholangiopancreatography (ERCP), when the probability of choledocholithiasis is intermediate (only one strong predictor)
- No associated morbidity and may be less costly than diagnostic ERCP
- Cholescintigraphy (HIDA/DISIDA scan): Isotope derivatives taken up by hepatocytes and excreted into biliary tree. Assesses bile duct obstruction, cystic duct obstruction, or bile leakage:
- May be combined with CCK to observe GB function and estimate GB ejection fraction
Diagnostic Procedures/Other
- Cholangiography is the gold standard for determining the presence of CBD stones:
- ERCP (sensitivity 83%, specificity 99%) (6): allows for papillotomy/stone extraction at time of diagnosis
- Percutaneous transhepatic cholangiography (PTC): Needle puncture of hepatic duct with injection of radiopaque dye. Used in patients with extensive bile duct stone disease or in whom ERCP would be difficult.
- Intraoperative cholangiography (IOC): Contrast in cystic duct during cholecystectomy. Ongoing debate if should be routine during cholecystectomy. Sensitivity 99%, specificity 99% (6)
- Endoscopic ultrasound (EUS): more likely to detect stones than transabdominal ultrasound (TUS):
- EUS or MRCP use can avoid ERCP in up to 67%.
- Intraoperative intraluminal ultrasonography:
- Can be performed during laparoscopic or open procedures. Sensitivity of 71-100% (2)[A]
- Helpful in patients with contrast dye allergy
- Postoperative studies:
- MRI (MRCP) to diagnose CBD stone
- T-tube cholangiography
- Choledochoscopy can be used to extract stones intraoperatively or via t-tube tract.
TREATMENT
Goal is to relieve obstruction. If not symptomatic, small stones may pass spontaneously.
MEDICATION
Antibiotics to cover enteric flora if infection is suspected
First Line
- Broad-spectrum antibiotics (substitute fluoroquinolones for penicillin-allergic patients)
- In absence of cholangitis, routine antibiotic prophylaxis prior to endoscopic procedure is not indicated, unless incomplete drainage is anticipated (e.g., PSC, hilar strictures).
- Antibiotics:
- Piperacillin-tazobactam (Zosyn): 3.375 g IV q6h (7,8)[A]
- Fluoroquinolones have good biliary penetration:
- Levofloxacin 750 mg/day IV
- Ciprofloxacin 400 mg IV BID (8)[A]
- Duration of therapy depends on rapidity of response, bacteremia, and subsequent need for surgery to correct biliary obstruction.
- Add metronidazole for anaerobic coverage in patients with sepsis, elderly patients, and patients with previous biliary manipulation (may not be necessary with newer broad-spectrum penicillins):
- Metronidazole 500 mg IV q8h (7,8)[A]
SURGERY/OTHER PROCEDURES
- ERCP with stone extraction is first-line management.
- Generally involves enlarging the papillary orifice, either by dividing sphincterotomy or papillary balloon dilation (1).
- High success rate (>98%) (7)
- Low complication rate (mortality 0.5%, pancreatitis 1.3-6.7%, perforation 0.1-1.1%, bleeding from sphincterotomy 0.3-2.0%, cholangitis 1%) (2)[A]
- Long-term biliary stenting is an acceptable alternative in frail patients with stones that are not endoscopically retrievable (1,7)[A] .
- Clinical situations with complicated biliary stone disease include (9)[A]:
- Stones >15 mm
- Stones associated with complicated biliary strictures (PSC, hepatolithiasis)
- Surgically altered anatomy (Roux-en-Y gastric bypass, Billroth II gastrojejunostomy)
- Mirizzi syndrome
- Consider transfer to a large volume, tertiary center to manage complicated biliary stone disease.
- If biliary stone is >10 mm, endoscopic sphincterotomy with endoscopic papillary balloon dilation, mechanical lithotripsy, electrohydraulic lithotripsy, or laser lithotripsy are possible options during ERCP (9)[A].
- Surgical CBD stone removal has a high success rate (75-95%) with few complications:
- Laparoscopic cholecystectomy with CBD exploration is as safe and efficient as ERCP (10)[A].
- First-stage management of symptomatic CBD stones with laparoscopic cholecystectomy + laparoscopic CBD exploration and second-stage management utilizing ERCP/EST (endoscopic sphincterotomy) + laparoscopic cholecystectomy, have similar stone clearance, similar morbidity, mortality, and length of hospital stay (10,11)[A].
- Consider a CBD lumen catheter if laparoscopic CBD exploration is not feasible and the chance of a CBD stone is <65%.
- Open choledochotomy is reserved for complex cases when laparoscopic and endoscopic techniques fail (unless patient is already undergoing an open procedure).
- Surgical drainage via external catheter or by papillotomy through ampulla of Vater
- Indications for drainage: sphincter of Oddi sclerosis or dysfunction, multiple or primary CBD stones, or previous stone
Admission Criteria/Initial Stabilization
- To control serious infection and urgently decompress CBD
- NPO, antibiotics, and IV hydration if infection suspected
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
After endoscopic bile duct clearance, patients should undergo cholecystectomy within 1 week (4)[A].
Patient Monitoring
- Serial liver function tests and bilirubin levels, WBC, and pancreatic enzymes as clinically indicated (2)[A]
- Patients with weight loss >25% from original weight after bariatric surgery may benefit from US surveillance and cholecystectomy if gallstones are identified (12)[A].
PROGNOSIS
- With treatment, prognosis is good.
- Untreated, 55% of patients will have complications.
COMPLICATIONS
- Cholangitis: most frequent (60%)
- Retained CBD stones (2-10%)
- Pancreatitis
- Pancreatitis following ERCP (incidence rate 1.3-6.7%)
- Biliary enteric fistula, hemobilia, bile duct injury, hepatic dysfunction/failure (rare)
REFERENCES
11 Trikudanathan G, Arain M, Attam R, et al. Advances in the endoscopic management of common bile duct stones. Nat Rev Gastroenterol Hepatol. 2014;11(9):535-544.22 Maple JT, Ben-Menachem T, Anderson MA, et al. The role of endoscopy in the evaluation of suspected choledocholithiasis. Gastrointest Endosc. 2010;71(1):1-9.33 Giljaca V, Gurusamy KS, Takwoingi Y, et al. Endoscopic ultrasound versus magnetic resonance cholangiopancreatography for common bile duct stones. Cochrane Database Syst Rev. 2015;(2):CD011549.44 Krawczyk M, Stokes CS, Lammert F. Genetics and treatment of bile duct stones: new approaches. Curr Opin Gastroenterol. 2013;29(3):329-335.55 Gurusamy KS, Giljaca V, Takwoingi Y, et al. Ultrasound versus liver function tests for diagnosis of common bile duct stones. Cochrane Database Syst Rev. 2015;(2):CD011548.66 Gurusamy KS, Giljaca V, Takwoingi Y, et al. Endoscopic retrograde cholangiopancreatography versus intraoperative cholangiography for diagnosis of common bile duct stones. Cochrane Database Syst Rev. 2015;(2):CD010339.77 Kochar R, Banerjee S. Infections of the biliary tract. Gastrointest Endosc Clin N Am. 2013;23(2):199-218.88 Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis. 2010;50(2):133-164.99 Maple JT, Ikenberry SO, Anderson MA, et al. The role of endoscopy in the management of choledocholithiasis. Gastrointest Endosc. 2011;74(4):731-744.1010 Dasari BV, Tan CJ, Gurusamy KS, et al. Surgical versus endoscopic treatment of bile duct stones. Cochrane Database Syst Rev. 2013;(12):CD003327.1111 Lu J, Cheng Y, Xiong XZ, et al. Two-stage vs single-stage management for concomitant gallstones and common bile duct stones. World J Gastroenterol. 2012;18(24):3156-3166.1212 Li VK, Pulido N, Fajnwaks P, et al. Predictors of gallstone formation after bariatric surgery: a multivariate analysis of risk factors comparing gastric bypass, gastric banding, and sleeve gastrectomy. Surg Endosc. 2009;23(7):1640-1644.
ADDITIONAL READING
- Abdelmajid K, Houssem H, Rafik G, et al. Open choldecho-enterostomy for common bile duct stones: is it out of date in laparo-endoscopic era? N Am J Med Sci. 2013;5(4):288-292.
- Alexakis N, Connor S. Meta-analysis of one- vs. two-stage laparoscopic/endoscopic management of common bile duct stones. HPB (Oxford). 2012;14(4):254-259.
- De Palma GD. Minimally invasive treatment of cholecysto-choledocal lithiasis: the point of view of the surgical endoscopist. World J Gastrointest Surg. 2013;5(6):161-166.
- Kharbutli B, Velanovich V. Management of preoperatively suspected choledocholithiasis: a decision analysis. J Gastrointest Surg. 2008;12(11):1973-1980.
- Rogers SJ, Cello JP, Horn JK, et al. Prospective randomized trial of LC+LCBDE vs ERCP/S+LC for common bile duct stone disease. Arch Surg. 2010;145(1):28-33.
- Trivedi PJ, Tse D, Al-Bakir I, et al. Appropriate patient selection in the management of common bile duct stones: when not to do ERCP. ISRN Surg. 2012;2012:286365.
SEE ALSO
Cholangitis, Acute; Cholecystitis; Cholelithiasis; Jaundice
CODES
ICD10
- K80.50 Calculus of bile duct w/o cholangitis or cholecyst w/o obst
- K80.51 Calculus of bile duct w/o cholangitis or cholecyst w obst
- K80.40 Calculus of bile duct w cholecystitis, unsp, w/o obstruction
- K80.41 Calculus of bile duct w cholecystitis, unsp, w obstruction
- K80.42 Calculus of bile duct w acute cholecystitis w/o obstruction
- K80.47 Calculus of bile duct w acute and chronic cholecyst w obst
- K80.46 Calculus of bile duct w acute and chronic cholecyst w/o obst
- K80.45 Calculus of bile duct w chronic cholecystitis w obstruction
- K80.43 Calculus of bile duct w acute cholecystitis with obstruction
- K80.44 Calculus of bile duct w chronic cholecyst w/o obstruction
ICD9
- 574.50 Calculus of bile duct without mention of cholecystitis, without mention of obstruction
- 574.51 Calculus of bile duct without mention of cholecystitis, with obstruction
- 574.30 Calculus of bile duct with acute cholecystitis, without mention of obstruction
- 574.31 Calculus of bile duct with acute cholecystitis, with obstruction
- 574.40 Calculus of bile duct with other cholecystitis, without mention of obstruction
- 574.41 Calculus of bile duct with other cholecystitis, with obstruction
SNOMED
- Common bile duct calculus (disorder)
- Calculus of common bile duct with acute cholecystitis
- Calculus of common bile duct with chronic cholecystitis
- Calculus of common bile duct with chronic cholecystitis without obstruction
- Calculus of common bile duct with acute cholecystitis without obstruction
- Calculus of common bile duct with acute cholecystitis with obstruction
- Calculus of common bile duct with chronic cholecystitis with obstruction
CLINICAL PEARLS
- Stones in the CBD are either primary (arising within the duct) or secondary (migrate into the duct from the gallbladder).
- Cholangiography is "gold standard" for diagnosis.
- MRCP is the most accurate noninvasive test.
- ERCP can be used in diagnosis and therapy.
- Cholangitis is most frequent complication.
- TUS is more useful for detecting CBD dilation (finding associated with choledocholithiasis) than detecting CBD stones.