Choledocholithiasis resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vendhan Ramanujam M.B.B.S [2]

Definitions

Terms	Definitions
Choledocholithiasis (bile duct stones)	Choledocholithiasis are crystallized pieces of bile including cholesterol and bilirubin in the bile duct. It usually refers to the gallstones that have migrated into the biliary tract from the gallbladder.
Primary choledocholithiasis	Primary choledocholithiasis are biliary tract stones resulting from biliary stasis and not from the migration of gallstones from the gallbladder into the biliary tract.
Asymptomatic choledocholithiasis	Asymptomatic choledocholithiasis refers to the presence of stones in the bile duct, that might be detected during imaging studies of the abdomen, in the absence of any symptoms.
Symptomatic and uncomplicated choledocholithiasis	Symptomatic and uncomplicated choledocholithiasis refers to the presence of stones in the bile duct that are associated with symptoms in the absence of complications such as acute cholangitis or pancreatitis.
Symptomatic and complicated choledocholithiasis	Symptomatic and complicated choledocholithiasis refers to the presence of stones in the bile duct with symptoms and complications such as acute cholangitis or pancreatitis.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

• Complicated cholelithiasis

Common Causes

• Cholelithiasis
• Primary choledocholithiasis

Management of Asymptomatic Choledocholithiasis

Shown below is a diagram depicting the management of choledocholithiasis according to American Society for Gastrointestinal Endoscopy (ASGE) and American Gastroenterological Association (AGA).

Incidental bile duct stones ❑ On noninvasive imaging for nonbiliary indications ❑ During evaluation of symptomatic cholelithiasis ❑ Intraoperatively during cholecystectomy

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CBD stones discovered during cholecystectomy

❑ Preoperative ERCP, and CBD stone removal, and ❑ Elective cholecystectomy

❑ Intraoperative CBD exploration and stone removal

❑ Postoperative ERCP, and CBD stone removal

Management of Symptomatic Choledocholithiasis

Characterize the symptoms: ❑ Symptomatic ❑ Aymptomatic

Symptomatic: ❑ Abdominal pain

Asymptomatic: Bile duct stones discovered incidentally ❑ On noninvasive imaging for nonbiliary indications ❑ During evaluation of symptomatic cholelithiasis ❑ Intraoperatively during cholecystectomy

❑ Acute or intermittent RUQ or epigastric pain ❑ Sharp, severe and steady pain ❑ Pain >6 hours ❑ Pain radiating to the right shoulder blade ❑ Pain radiating to the back ❑ Pain after food intake ❑ Jaundice ❑ Pale stools ❑ Dark urine ❑ Fever ❑ Nausea & vomiting ❑ Diaphoresis ❑ Altered mental status ❑ history of recurrent symptoms ❑ history of previous GB disease

Asymptomatic choledocholithiasis

Examine the patient: ❑ Altered mental status ❑ Fever ❑ Dehydration ❑ Jaundice ❑ Hypotension ❑ Tachycardia ❑ Dyspnea ❑ Hypoxemia ❑ Abdominal tenderness

CBD stones discovered during imaging

CBD stones discovered during cholecystectomy

Order laboratory tests: ❑ CBC ❑ BMP ❑ CRP ❑ Total bilirubin ❑ Direct bilirubin ❑ Albumin ❑ AST ❑ ALT ❑ Alkaline phosphatase ❑ GGT ❑ Amylase ❑ Lipase

Preoperative ERCP & CBD stone removal, & elective cholecystectomy

Intraoperative CBD exploration & stone removal or postoperative ERCP & CBD stone removal

Suspect symptomatic choledocholithiasis: Symptomatic & uncomplicated choledocholithiasis: ❑ Acute or intermittent RUQ or epigastric pain, >6 hours & associated w/ nausea & vomiting ❑ Elevated bilirubin, alkaline phosphatase and GGT levels

Symptomatic & complicated choledocholithiasis: Features of symptomatic & uncomplicated choledocholithiasis w/ Acute cholangitis: ❑ Fever, jaundice & leukocytosis Biliary pancreatitis: ❑ Elevated amylase & lipase

Consider severity assessment & management for acute cholangitis & biliary pancreatitis accordingly

Order transabdominal USG (TAUSG)

Diagnostic predictors: Very strong: ❑ Bilirubin >4 mg/dL ❑ CBD stone on TAUSG ❑ Clinical ascending cholangitis ❑ Fever ❑ Jaundice ❑ RUQ pain Strong: ❑ Bilirubin 1.8-4 mg/dL ❑ Dilated CBD (>6 mm with GB in situ) on TAUSG Moderate: ❑ Age >55 years ❑ Abnormal LFT other than bilirubin (elevated alkaline phosphatase & GGT) ❑ Clinical biliary pancreatitis ❑ Severe epigastric pain radiating to the back ❑ Abdominal tenderness ❑ Nausea ❑ Vomiting ❑ Fever ❑ Dyspnea ❑ Tachycardia ❑ Hypotension ❑ Hypoxemia

No predictors

One strong and/or at least one moderate predictor

Presence of any very strong or both strong predictors

Low risk

Intermediate risk

High risk

GBS or biliary sludge seen during TAUSG

Laparoscopic IOC or US

Preoperative EUS/MRCP

CBD stones present or test unavailable

Preoperative ERCP & CBD stone removal

Cholecystectomy w/o preoperative EUS/MRCP or intraoperative cholangiography/US/CBD exploration

CBD stones present

CBD stones absent

If GBS or sludge seen during imaging

Intraoperative CBD exploration & stone removal

Postoperative ERCP & CBD stone removal

Elective cholecystectomy

^†ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; BMP: Basic Metabolic Profile; CBC: Complete Blood Count; CBD: Common Bile Duct; CRP: C-reactive protein; ERCP: Endoscopic retrograde cholangiopancreatography; EUS: Endoscopic ultrasound; GB: Gallbladder; GBS: Gallbladder stone; GGT: Gamma-glutamyl transpeptidase; IOC: Intraoperative cholangiography; LFT: Liver function tests; MRCP: Magnetic resonance cholangiopancreatography; RUQ: Right Upper Quadrant; Sx: Symptom; US: Ultrasound; W/: With; W/O: Without

Do's

• Initial evaluation of suspected choledocholithiasis should include serum liver biochemical tests and a transabdominal ultrasound of the right upper quadrant. These tests should be used to risk-stratify patients to guide further evaluation and management (Grade B).
• EUS or MRCP can be considered in the diagnostic evaluation of postcholecystectomy patients suspected of having choledocholithiasis when initial laboratory and ultrasonography data are abnormal yet non diagnostic (Grade C).
• Sphincter of Oddi dysfunction should be considered as a differential diagnosis if EUS or MRCP did not detect any stones in the bile duct of postcholecystectomy patients suspected of having choledocholithiasis.
• Laparoscopic cholecystectomy is preferred over open but conversion to open may be necessary and should not be considered a failure in management.

Dont's

• Laparoscopic cholecystectomy is contraindicated in untreated coagulopathy, lack of equipment, lack of surgeon expertise, hostile abdomen, advanced cirrhosis/liver failure, and suspected gallbladder cancer.

Grade System for Rating the Quality of Evidence

The grade system for rating the quality of evidence is as follows.

Quality of evidence	Definition
High quality (Grade A)	Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality (Grade B)	Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality (Grade C)	Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality (Grade D)	Any estimate of effect is very uncertain.

References

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