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Choledocholithiasis - Clinical Manifestations, Diagnosis, and Management - UpToDate
Choledocholithiasis - Clinical Manifestations, Diagnosis, and Management - UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2018 UpToDate, Inc. and/or its affiliates. All Rights Reserved.
Choledocholithiasis: Clinical manifestations, diagnosis, and management
Authors: Mustafa A Arain, MD, Martin L Freeman, MD
Section Editor: Douglas A Howell, MD, FASGE, FACG
Deputy Editor: Shilpa Grover, MD, MPH, AGAF
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Aug 2018. | This topic last updated: Aug 10, 2017.
INTRODUCTION — Choledocholithiasis refers to the presence of gallstones within the common bile duct.
According to the National Health and Nutrition Examination Survey (NHANES III), over 20 million Americans are
estimated to have gallbladder disease (defined as the presence of gallstones on transabdominal ultrasound or a
history of cholecystectomy) [1]. Among those with gallbladder disease, the exact incidence and prevalence of
choledocholithiasis are not known, but it has been estimated that 5 to 20 percent of patients have
choledocholithiasis at the time of cholecystectomy, with the incidence increasing with age [28].
In Western countries, most cases of choledocholithiasis are secondary to the passage of gallstones from the
gallbladder into the common bile duct. Primary choledocholithiasis (ie, formation of stones within the common bile
duct) is less common. Primary choledocholithiasis typically occurs in the setting of bile stasis (eg, patients with
cystic fibrosis), resulting in a higher propensity for intraductal stone formation. Older adults with large bile ducts
and periampullary diverticular are at elevated risk for the formation of primary bile duct stones. Patients with
recurrent or persistent infection involving the biliary system are also at risk, a phenomenon seen most commonly
in populations from East Asia. (See "Recurrent pyogenic cholangitis".)
The causes of primary choledocholithiasis often affect the biliary tract diffusely, so patients may have both
extrahepatic and intrahepatic biliary stones. Intrahepatic stones may be complicated by recurrent pyogenic
cholangitis.
This topic will review the clinical manifestations and diagnosis of choledocholithiasis. The treatment of
choledocholithiasis, as well as the epidemiology and the general management of patients with gallstones, are
discussed separately:
● (See "Endoscopic management of bile duct stones: Standard techniques and mechanical lithotripsy".)
● (See "Epidemiology of and risk factors for gallstones".)
● (See "Approach to the management of gallstones".)
● (See "Overview of gallstone disease in adults".)
● (See "Patient selection for the nonsurgical treatment of gallstone disease".)
● (See "Nonsurgical treatment of gallstones".)
CLINICAL MANIFESTATIONS — Patients with choledocholithiasis typically present with biliarytype pain and
laboratory testing that reveals a cholestatic pattern of liver test abnormalities (ie, elevated bilirubin and alkaline
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phosphatase). Patients with uncomplicated choledocholithiasis are typically afebrile and have a normal complete
blood count and pancreatic enzyme levels. Occasionally, patients are asymptomatic. In such patients, the
diagnosis may be suspected because of abnormal liver blood tests, abnormalities seen on imaging studies
obtained for unrelated reasons, or when an intraoperative cholangiogram obtained during cholecystectomy
suggests the presence of a common bile duct stone. (See "Approach to the patient with abnormal liver
biochemical and function tests", section on 'Patterns of liver test abnormalities'.)
Complications of choledocholithiasis include acute pancreatitis and acute cholangitis. Patients with acute
pancreatitis typically have elevated serum pancreatic enzyme levels, and patients with acute cholangitis are often
febrile with a leukocytosis. Rarely, patients with longstanding biliary obstruction develop secondary biliary
cirrhosis. (See 'Complicated choledocholithiasis' below.)
Uncomplicated choledocholithiasis
Symptoms — Most patients with choledocholithiasis are symptomatic, although occasional patients are
asymptomatic. Symptoms associated with choledocholithiasis include right upper quadrant or epigastric pain,
nausea, and vomiting. The pain is often more prolonged than is seen with typical biliary colic (which typically
resolves within six hours). (See "Overview of gallstone disease in adults", section on 'Biliary colic'.)
The pain from choledocholithiasis resolves when the stone either passes spontaneously or is removed. Some
patients have intermittent pain due to transient blockage of the common bile duct. Transient blockage occurs
when there is retention and floating of stones or debris within the bile duct, a phenomenon referred to as a "ball
valve" effect.
Physical examination — On physical examination, patients with choledocholithiasis often have right upper
quadrant or epigastric tenderness. Patients may also appear jaundiced. Courvoisier's sign (a palpable gallbladder
on physical examination) may be seen when gallbladder dilation develops because of an obstruction of the
common bile duct. It is more often associated with malignant common bile duct obstruction, but has been
reported with choledocholithiasis [9].
Laboratory tests — Serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST)
concentrations are typically elevated early in the course of biliary obstruction. Later, liver tests are typically
elevated in a cholestatic pattern, with increases in serum bilirubin, alkaline phosphatase, and gammaglutamyl
transpeptidase (GGT) exceeding the elevations in serum ALT and AST. (See "Approach to the patient with
abnormal liver biochemical and function tests", section on 'Patterns of liver test abnormalities'.)
Studies have attempted to estimate the predictive value of liver chemistry tests for choledocholithiasis [8,1012]:
● A metaanalysis of 22 studies evaluated the predictive role of multiple examination findings and tests used in
the diagnosis of choledocholithiasis, including serum bilirubin and alkaline phosphatase [10]. An elevation in
serum bilirubin had a sensitivity of 69 percent and a specificity of 88 percent for diagnosing a common bile
duct stone. For elevations in serum alkaline phosphatase, the values were 57 and 86 percent, respectively.
● A study of 1002 patients who underwent laparoscopic cholecystectomy for cholelithiasis evaluated five liver
related biochemical tests for predicting choledocholithiasis: serum GGT, alkaline phosphatase, total bilirubin,
ALT, and AST [11]. The sensitivities ranged from 64 percent for AST to 84 percent for GGT, and the
specificities ranged from 68 percent for ALT to 88 percent for bilirubin. Elevated serum GGT, alkaline
phosphatase, and bilirubin levels were independent predictors of a common bile duct stone on multivariable
analysis (odds ratios of 3.2, 2.0, and 1.4, respectively).
Since liver tests may be elevated due to a wide variety of etiologies, the positive predictive value of elevated liver
tests is poor. On the other hand, the negative predictive value of normal liver tests is high. Thus, normal liver
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tests play a greater role in excluding choledocholithiasis than elevated liver tests play in diagnosing stones.
Improving liver blood tests combined with symptom resolution suggests that a patient with choledocholithiasis
has spontaneously passed the gallstone.
Complicated choledocholithiasis — The two major complications associated with choledocholithiasis are
pancreatitis and acute cholangitis. In addition to the findings associated with uncomplicated choledocholithiasis,
patients with biliary pancreatitis typically present with nausea, vomiting, elevations in serum amylase and lipase
(by definition greater than three times the upper limit of normal), and/or imaging findings suggestive of acute
pancreatitis. (See "Clinical manifestations and diagnosis of acute pancreatitis".)
Patients with acute cholangitis often present with Charcot's triad (fever, right upper quadrant pain, and jaundice)
and leukocytosis. In severe cases, bacteremia and sepsis may lead to hypotension and altered mental status
(Reynolds' pentad). (See "Acute cholangitis: Clinical manifestations, diagnosis, and management", section on
'Clinical manifestations'.)
Longstanding biliary obstruction from various causes, including common bile duct stones, may result in liver
disease that may progress to cirrhosis, a phenomenon referred to as secondary biliary cirrhosis [1,2]. Although
rare in the setting of bile duct stones, secondary biliary cirrhosis may eventually result in the same cirrhosis
related complications that occur with other etiologies. Relief of biliary obstruction has been shown to result in
regression of liver fibrosis in patients with secondary biliary cirrhosis in the setting of chronic pancreatitis and
choledochal cysts [3,4]. It is likely, but not known, whether stone removal results in similar improvement in liver
disease in patients with choledocholithiasisinduced secondary biliary cirrhosis.
DIAGNOSIS — Patients suspected of having choledocholithiasis are diagnosed with a combination of laboratory
tests and imaging studies. The first imaging study obtained is typically a transabdominal ultrasound. Additional
testing may include magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasound (EUS),
and/or endoscopic retrograde cholangiopancreatography (ERCP).
The aim of the diagnostic evaluation is to confirm or exclude the presence of common bile duct stones using the
least invasive, most accurate, and most costeffective imaging modality [13]. The specific approach is determined
by the level of clinical suspicion, availability of imaging modalities, and patient factors (eg, contraindications to a
particular test) (algorithm 1). (See 'Diagnostic approach' below.)
Diagnostic approach — Patients are often suspected of having choledocholithiasis when they present with right
upper quadrant pain with elevated liver enzymes in a primarily cholestatic pattern (disproportionate elevation of
the alkaline phosphatase, gammaglutamyl transferase, and bilirubin). In a patient suspected of having
choledocholithiasis based on the history, physical exam, and laboratory testing, we start by obtaining a
transabdominal ultrasound. If not already done, we also obtain a complete blood count to look for leukocytosis
(which may suggest acute cholangitis has developed) and pancreatic enzyme levels. (See 'Transabdominal
ultrasound' below.)
We then use the results of laboratory tests and transabdominal ultrasound to stratify a patient as high risk,
intermediate risk, or low risk for having choledocholithiasis. Subsequent management varies depending on the
patient's level of risk (algorithm 1). (See 'Risk assessment' below.):
● Patients at high risk proceed to ERCP with stone removal, followed by elective cholecystectomy.
● Patients at intermediate risk either undergo preoperative EUS or MRCP, or they proceed to laparoscopic
cholecystectomy with intraoperative cholangiography or ultrasonography. If a stone is found preoperatively,
patients should proceed to ERCP with stone removal, followed by elective cholecystectomy, provided
gallstones or sludge were seen on preoperative imaging.
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● Patients at low risk can proceed directly to cholecystectomy without additional testing, provided gallstones or
sludge were seen on preoperative imaging.
Risk assessment — In a 2010 guideline, the American Society for Gastrointestinal Endoscopy (ASGE)
proposed the following approach to stratify patients based on their probability of having choledocholithiasis.
Patients were stratified using the following predictors [14]:
● "Very strong" predictors
• The presence of a common bile duct stone on transabdominal ultrasound
• Clinical acute cholangitis
• A serum bilirubin greater than 4 mg/dL (68 micromol/L)
● "Strong" predictors
• A dilated common bile duct on ultrasound (more than 6 mm in a patient with a gallbladder in situ)
• A serum bilirubin of 1.8 to 4 mg/dL (31 to 68 micromol/L)
● "Moderate" predictors
• Abnormal liver biochemical test other than bilirubin
• Age older than 55 years
• Clinical gallstone pancreatitis
Using the above predictors, patients are stratified as:
● High risk
• At least one very strong predictor and/or
• Both strong predictors
● Intermediate risk
• One strong predictor and/or
• At least one moderate predictor
● Low risk
• No predictors
Highrisk patients — Patients categorized as being high risk for choledocholithiasis have an estimated
probability of having a common bile duct stone of >50 percent [14]. In such patients, the appropriate first step in
treatment is ERCP with removal of any common bile duct stones, followed by elective cholecystectomy. (See
'Endoscopic retrograde cholangiopancreatography' below and "Endoscopic management of bile duct stones:
Standard techniques and mechanical lithotripsy".)
Intermediaterisk patients — Intermediaterisk patients have an estimated 10 to 50 percent probability of
having a common bile duct stone. Such patients require evaluation to rule out choledocholithiasis, but the risk is
not high enough to warrant going directly to ERCP [14]. Less invasive options for detecting choledocholithiasis
include EUS and MRCP. Deciding which test should be performed first depends on various factors such as ease
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of availability, cost, patientrelated factors, and the suspicion for a small stone (table 1). (See 'EUS and MRCP'
below.)
Because it is noninvasive, MRCP is often the first test performed to look for stones. If positive, patients should
undergo ERCP. In most cases, if the MRCP is negative the patient can proceed to elective cholecystectomy
(provided gallstones or biliary sludge were demonstrated on preoperative imaging). However, if the MRCP is
negative, but the suspicion for a common bile duct stone remains moderate to high (eg, in a patient whose
laboratory tests are not improving), EUS is an appropriate next step. In many centers, the endoscopist performing
the EUS can perform an ERCP during the same session if a stone is found.
An alternative to preoperative imaging is to proceed to laparoscopic cholecystectomy with intraoperative
cholangiography or ultrasonography, provided a surgeon who is experienced with the techniques is available.
This approach was examined in a randomized trial with 100 patients at intermediate risk of having a common bile
duct stone [15]. Patients were assigned to either proceed directly to laparoscopic cholecystectomy with
intraoperative cholangiography or to initial EUS followed by ERCP if positive, and subsequent laparoscopic
cholecystectomy. Patients who proceeded directly to surgery had a shorter median length of stay than those who
underwent EUS first (5 versus 8 days) and overall had fewer EUSs, MRCPs, and ERCPs (25 versus 71). There
were no differences between the groups with regard to conversion to laparotomy, time in the operating room,
complications, or death. (See 'Intraoperative cholangiography' below and 'Intraoperative ultrasonography' below.)
Lowrisk patients — Lowrisk patients are estimated to have a <10 percent probability of having a common
bile duct stone [14]. If gallstones or sludge are present within the gallbladder on transabdominal ultrasound and
the patient is a good surgical candidate, the patient should proceed to cholecystectomy without imaging of the
common bile duct preoperatively or intraoperatively. Alternative therapies, such as medical gallstone dissolution,
may be considered for patients who are not surgical candidates. (See "Nonsurgical treatment of gallstones".)
If there is no evidence of gallstones on imaging, alternative explanations for the patient's pain should be sought.
(See "Evaluation of the adult with abdominal pain".)
Special circumstances
Concomitant acute pancreatitis — Whether to proceed directly to ERCP in patients with acute
pancreatitis depends on whether the patient also has acute cholangitis. Patients with both acute pancreatitis and
acute cholangitis should undergo early ERCP [14]. However, it is less clear if patients with acute pancreatitis
without cholangitis benefit from early ERCP [16]. Current evidence supports early ERCP in patients with ongoing
evidence of biliary obstruction, but it no longer supports early ERCP in patients with severe pancreatitis alone
[17].
In patients with acute pancreatitis but equivocal evidence of bile duct stones (eg, improving liver enzyme tests
and/or improvement or resolution of pain), MRCP or EUS followed by ERCP only if the EUS/MRCP reveals a
common bile duct stone is an attractive option because it can detect common bile duct stones, but is not
associated with pancreatitis.
Issues related to ERCP in patients with acute biliary pancreatitis are discussed elsewhere. (See "Management of
acute pancreatitis", section on 'Endoscopic retrograde cholangiopancreatography'.)
Prior cholecystectomy — Choledocholithiasis will sometimes be suspected in a patient who has
previously undergone cholecystectomy. Choledocholithiasis can occur in this setting if a gallstone escapes from
the gallbladder during cholecystectomy or if there is de novo stone formation within the common bile duct. (See
'Introduction' above and "Laparoscopic cholecystectomy", section on 'Postcholecystectomy syndrome'.)
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In such patients, transabdominal ultrasound is less helpful because a dilated common bile duct seen on
ultrasound may be the result of a common bile duct stone, or it may be the result of the cholecystectomy.
Following cholecystectomy, the common bile duct may dilate to 10 mm. (See "Ultrasonography of the
hepatobiliary tract", section on 'Normal measurements on ultrasound'.)
One approach to patients who have undergone a prior cholecystectomy and who present with biliarytype pain
and liver test abnormalities, but in whom there is uncertainty as to presence of a bile duct stone, is to proceed
with an MRCP or EUS to confirm the presence of a stone. If a stone is seen, proceeding with ERCP for stone
removal is the next step. If a stone is absent, then the patient may have sphincter of Oddi dysfunction, and the
approach to possible ERCP should be modified to include specific informed consent regarding higher risk of
ERCP in this setting and the decreased benefit from sphincterotomy. In addition, the ERCP techniques used
should focus on risk reduction, with liberal use of protective pancreatic stents [18] and consideration of rectal
indomethacin [19]. (See "Treatment of sphincter of Oddi dysfunction", section on 'Endoscopic sphincterotomy'
and "Prophylactic pancreatic stents to prevent ERCPinduced pancreatitis: When do you use them?", section on
'Sphincter of Oddi dysfunction or a small bile duct' and "Postendoscopic retrograde cholangiopancreatography
(ERCP) pancreatitis", section on 'Rectal NSAIDs'.)
Imaging test characteristics — Several imaging modalities can be used for the evaluation of patients with
suspected choledocholithiasis, including:
● Transabdominal ultrasound
● ERCP
● EUS
● MRCP
● Intraoperative cholangiography or ultrasonography
Transabdominal ultrasound — The initial imaging study of choice in patients with suspected common bile
duct stones is a transabdominal ultrasound of the right upper quadrant. Transabdominal ultrasound can evaluate
for cholelithiasis, choledocholithiasis, and common bile duct dilation. It is readily available, noninvasive, permits
bedside evaluation, and provides a lowcost means of evaluating the common bile duct for stones. (See
"Ultrasonography of the hepatobiliary tract".)
The sensitivity of transabdominal ultrasound for choledocholithiasis ranges from 20 to 90 percent [14]. In a meta
analysis of five studies, the pooled sensitivity of ultrasound for detecting a common bile duct stone was 73
percent, with a specificity of 91 percent [20]. Transabdominal ultrasound has poor sensitivity for stones in the
distal common bile duct because the distal common bile duct is often obscured by bowel gas in the imaging field
[2125]. Occasionally, a definite common bile duct stone (one that casts a shadow) can be imaged by
transabdominal ultrasound (image 1).
A dilated common bile duct on transabdominal ultrasound is suggestive of, but not specific for,
choledocholithiasis [6,8,10]. A cutoff of 6 mm is often used to classify a duct as being dilated [14]. However, using
a cutoff of 6 mm may miss stones [26]. One study of 870 patients undergoing cholecystectomy found that stones
were often detected in patients whose ducts would have been classified as "nondilated" using the 6 mm cutoff
[27]. In addition, the probability of a stone in the common bile duct increased with increasing common bile duct
diameter:
● 0 to 4 mm: 3.9 percent
● 4.1 to 6 mm: 9.4 percent
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● 6.1 to 8 mm: 28 percent
● 8.1 to 10 mm: 32 percent
● >10 mm: 50 percent
Conversely, because the diameter of the common bile duct increases with age, older adults may have a normal
duct with a diameter that is >6 mm. (See "Ultrasonography of the hepatobiliary tract", section on 'Normal
measurements on ultrasound'.)
Endoscopic retrograde cholangiopancreatography — Traditionally, ERCP (image 2) was used both as a
diagnostic and therapeutic procedure in patients with suspected choledocholithiasis. The sensitivity of ERCP for
choledocholithiasis is estimated to be 80 to 93 percent, with a specificity of 99 to 100 percent [28,29]. However,
ERCP is invasive, requires technical expertise, and is associated with complications such as pancreatitis,
bleeding, and perforation. As a result, ERCP is now reserved for patients who are at high risk for having a
common bile duct stone, particularly if there if evidence of cholangitis, or who have had a stone demonstrated on
other imaging modalities. (See 'Highrisk patients' above and "Endoscopic retrograde cholangiopancreatography:
Indications, patient preparation, and complications".)
EUS and MRCP — EUS (image 3) and MRCP (picture 1) have largely replaced ERCP for the diagnosis of
choledocholithiasis in patients at intermediate risk for choledocholithiasis. EUS is less invasive than ERCP, and
MRCP is noninvasive. Both tests are highly sensitive and specific for choledocholithiasis [30]. Deciding which test
should be performed first depends on various factors such as ease of availability, cost, patientrelated factors,
and the suspicion for a small stone (table 1). (See 'Intermediaterisk patients' above and "Magnetic resonance
cholangiopancreatography" and "Endoscopic ultrasound in patients with suspected choledocholithiasis".)
EUS and MRCP for the diagnosis of choledocholithiasis have been evaluated using ERCP as the reference
standard:
● A metaanalysis of 27 studies with 2673 patients found that EUS had a sensitivity of 94 percent and a
specificity of 95 percent [31].
● A review of 13 studies found that MRCP had a median sensitivity of 93 percent and a median specificity of
94 percent [32].
Studies have prospectively compared the accuracy of EUS with MRCP in the diagnosis of choledocholithiasis.
These have been reviewed in two systemic reviews, both of which showed no significant differences between the
two modalities [33,34]. In a pooled analysis of 301 patients from five randomized trials that compared EUS with
MRCP, there was no statistically significant difference in aggregated sensitivity (93 versus 85 percent) or
specificity (96 versus 93 percent).
MRCP is preferred for many patients because it is noninvasive. However, the sensitivity of MRCP may be lower
for small stones (<6 mm, (image 3)) [35], and biliary sludge can be detected by EUS, but generally not by MRCP.
As a result, EUS should be considered in patients in whom the suspicion for choledocholithiasis remains
moderate to high despite a negative MRCP. (See 'Intermediaterisk patients' above.)
Intraoperative cholangiography — Intraoperative cholangiography has an estimated sensitivity of 59 to 100
percent for diagnosing choledocholithiasis, with a specificity of 93 to 100 percent [29,36,37]. However, it is highly
operatordependent and is not routinely performed by many surgeons [38].
In the era prior to laparoscopic surgery, patients with gallstone disease and suspected choledocholithiasis
underwent open cholecystectomy including cholangiography and palpation of the common bile duct and/or open
exploration of the common bile duct to diagnose and treat choledocholithiasis. As laparoscopic surgery replaced
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open surgery as the preferred method for cholecystectomy, exploration of the common bile duct for removal of
intraductal stones became technically more challenging. (See "Laparoscopic cholecystectomy", section on
'Evaluation for choledocholithiasis' and "Surgical common bile duct exploration", section on 'Intraoperative
cholangiography'.)
With improvements in cholangiography techniques and the use of fluoroscopic rather than static cholangiography,
the successful completion rate and accuracy of intraoperative cholangiography have improved over time [39]. In
practice, the use of intraoperative cholangiography is highly operatordependent and may be technically
unfeasible in patients with a severely inflamed gallbladder or with a tiny or inflamed cystic duct.
Studies of intraoperative cholangiography during laparoscopic cholecystectomy have shown the following:
● In a review of 13 studies with 1980 patients undergoing laparoscopic cholecystectomy, 9 percent had
choledocholithiasis [36]. The success rate for technical completion of intraoperative cholangiography ranged
from 88 to 100 percent. Intraoperative cholangiography had a sensitivity of 68 to 100 percent and a
specificity of 92 to 100 percent for diagnosing choledocholithiasis.
● In a more recent prospective populationbased study, intraoperative cholangiography was routinely
attempted in 1171 patients undergoing cholecystectomy [37]. The cholecystectomy was carried out
laparoscopically in 79 percent. Intraoperative cholangiography was successful in 95 percent, and
choledocholithiasis was identified in 134 patients (11 percent). The sensitivity and specificity of intraoperative
cholangiography were 97 and 99 percent, respectively.
There is ongoing debate about the routine use of intraoperative cholangiography in all patients undergoing
laparoscopic cholecystectomy versus selective use in patients at increased risk for intraductal stones, and
practices vary widely among surgeons. Proponents of routine intraoperative cholangiography argue that it permits
delineation of biliary anatomy, reduces and identifies bile duct injuries, and identifies asymptomatic
choledocholithiasis. Opponents argue that intraoperative cholangiography adds to procedure time and expense.
In addition, they argue that asymptomatic common bile duct stones may pass spontaneously and/or have a low
potential for causing complications, such that their identification may lead to unnecessary common bile duct
exploration and/or conversion to open surgery [4050].
A 2008 study examined the frequency with which surgeons employ intraoperative cholangiography. In the survey
of 1417 surgeons, 27 percent defined themselves as routine intraoperative cholangiography users [38]. Among
the routine users, 91 percent reported using intraoperative cholangiography in more than 75 percent of
laparoscopic cholecystectomies. Academic surgeons were less often routine users compared with nonacademic
surgeons (15 versus 30 percent).
Intraoperative ultrasonography — Another intraoperative approach for detecting choledocholithiasis is
intraoperative ultrasonography. During laparoscopy, an ultrasound probe is inserted into the peritoneal cavity
though a 10mm trochar and is used to scan the bile ducts. The reported sensitivity and specificity are over 90
percent, and it has been suggested that the routine use of intraoperative ultrasound followed by selective
intraoperative cholangiography leads to the accurate diagnosis of choledocholithiasis, while reducing the need for
intraoperative cholangiography [51].
The use of intraoperative ultrasound may also decrease the rate of bile duct injury [52]. Compared with
intraoperative cholangiography, intraoperative ultrasound does not require entry into the bile duct. However, it is
associated with a longer learning curve and is currently not as widely available [36]. The decision regarding
intraoperative cholangiography or intraoperative ultrasonography depends upon patient selection and the
surgeon's expertise and comfort with the techniques.
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Other imaging modalities — Abdominal computed tomography (CT) and percutaneous
cholangiopancreatography are alternative methods for diagnosing choledocholithiasis. Unenhanced abdominal
CT is neither sensitive nor specific for choledocholithiasis. However, both sensitivity and specificity can be
improved with the use of intravenous contrast media combined with a helical cholangiography protocol,
increasing from 65 to 93 percent and from 84 to 100 percent, respectively [5358]. If a common bile duct stone is
clearly visualized on CT (image 4), the finding is highly specific. (See "Computed tomography of the hepatobiliary
tract".)
Percutaneous transhepatic cholangiography is typically performed in patients who are not candidates for ERCP,
who have failed ERCP, who have surgically altered anatomy preventing endoscopic access to the biliary tree, or
who have intrahepatic stones. Due to its invasive nature, it should generally be considered a therapeutic
procedure, rather than a diagnostic one. (See "Percutaneous transhepatic cholangiography".)
DIFFERENTIAL DIAGNOSIS — Patients with uncomplicated gallstone disease, acute cholecystitis, sphincter of
Oddi dysfunction, or functional gallbladder disorder may all present with biliary colic, and patients with liver
disease, hematologic disorders, or biliary obstruction from any cause may present with jaundice (table 2).
Choledocholithiasis can typically be differentiated from these other entities based on the patient's history,
laboratory tests, and abdominal imaging.
Patients with choledocholithiasis typically present acutely with prolonged episodes of pain. On the other hand,
the episodes of pain in patients with uncomplicated gallstone disease, sphincter of Oddi dysfunction, or functional
gallbladder disorder typically last less than six hours and often occur intermittently. In addition, patients with
uncomplicated gallstone disease or functional gallbladder disorder should have normal laboratory tests and
imaging (though patients with sphincter of Oddi dysfunction may have bile duct dilation and elevations in the
alanine aminotransferase, aspartate aminotransferase, and alkaline phosphatase that normalize between
attacks). Endoscopic ultrasound or magnetic resonance cholangiopancreatography may be required to
differentiate between sphincter of Oddi dysfunction and choledocholithiasis. (See "Overview of gallstone disease
in adults" and "Clinical manifestations and diagnosis of sphincter of Oddi dysfunction" and "Functional gallbladder
disorder in adults".)
Like patients with choledocholithiasis, patients with acute cholecystitis may have prolonged episodes of pain that
start suddenly. However, patients with acute cholecystitis should not have a significantly elevated bilirubin or
alkaline phosphatase unless there is a secondary process causing cholestasis. In addition, abdominal imaging in
acute cholecystitis typically reveals a normal common bile duct, gallbladder wall thickening, and a sonographic
Murphy's sign. (See "Acute cholecystitis: Pathogenesis, clinical features, and diagnosis".)
There are numerous causes of jaundice in addition to choledocholithiasis (table 2). Choledocholithiasis is
differentiated from these other conditions by the presence of biliarytype pain and sometimes by a dilated
common bile duct on abdominal imaging. (See "Diagnostic approach to the adult with jaundice or asymptomatic
hyperbilirubinemia", section on 'Causes of hyperbilirubinemia'.)
MANAGEMENT — The mainstay of the management of choledocholithiasis is removal of the common bile duct
stone either endoscopically or surgically. It is also important to identify and treat the complications of
choledocholithiasis, such as acute pancreatitis and acute cholangitis. (See "Management of acute pancreatitis"
and "Acute cholangitis: Clinical manifestations, diagnosis, and management", section on 'Management'.)
The approach to stone removal depends on when the stone is discovered. If the stone is detected before or after
cholecystectomy, the stone should be removed with endoscopic retrograde cholangiopancreatography (ERCP).
(See "Endoscopic management of bile duct stones: Standard techniques and mechanical lithotripsy".)
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The choice of treatment for patients with choledocholithiasis found during surgery includes intraoperative ERCP,
intraoperative common bile duct exploration (laparoscopic or open), and postoperative ERCP. At our center,
intraoperative ERCP is performed if consent was obtained preoperatively. Otherwise, ERCP is performed at a
later time during the same hospitalization, as is standard in most practice settings. (See 'Intraoperative
cholangiography' above and 'Intraoperative ultrasonography' above.)
Intraoperative common bile duct exploration is performed selectively, based on surgeon preference and local
expertise. Open common bile duct exploration is more widely available than laparoscopic common bile duct
exploration but is associated with significantly more complications [59]. In selected centers, laparoscopic
common bile duct exploration and stone removal is routinely performed. There are relatively few indications for
open common bile duct exploration, but cholecystectomy in patients with surgically altered anatomy (eg, Roux
enY gastric bypass) may be an example of an appropriate setting. (See "Surgical common bile duct exploration"
and "Open cholecystectomy", section on 'Common bile duct exploration'.)
SOCIETY GUIDELINE LINKS — Links to society and governmentsponsored guidelines from selected countries
and regions around the world are provided separately. (See "Society guideline links: Cholecystitis and other
gallbladder disorders".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and
"Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade
reading level, and they answer the four or five key questions a patient might have about a given condition. These
articles are best for patients who want a general overview and who prefer short, easytoread materials. Beyond
the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written
at the 10th to 12th grade reading level and are best for patients who want indepth information and are
comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or email these
topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on
"patient info" and the keyword(s) of interest.)
● Beyond the Basics topics (see "Patient education: ERCP (endoscopic retrograde cholangiopancreatography)
(Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
● Choledocholithiasis refers to the presence of gallstones within the common bile duct. It has been estimated
that 5 to 20 percent of patients with gallstones will have choledocholithiasis at the time of cholecystectomy,
with the incidence increasing with age. (See 'Introduction' above.)
● Most patients with choledocholithiasis are symptomatic, although occasional patients are asymptomatic.
Symptoms associated with choledocholithiasis include right upper quadrant or epigastric pain, nausea, and
vomiting. The pain is often more prolonged than is seen with typical biliary colic (which typically resolves
within six hours). (See 'Symptoms' above.)
● On physical examination, patients with choledocholithiasis often have right upper quadrant or epigastric
tenderness. Patients may also appear jaundiced. (See 'Physical examination' above.)
● Serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) are typically elevated early in
the course of biliary obstruction. Later, liver tests are typically elevated in a cholestatic pattern, with
elevations in serum bilirubin, alkaline phosphatase, and gammaglutamyl transpeptidase being more
pronounced than those in ALT and AST. (See 'Laboratory tests' above.)
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● Complications of choledocholithiasis include acute pancreatitis and acute cholangitis. Patients with acute
pancreatitis typically have elevated serum pancreatic enzyme levels, and patients with acute cholangitis are
often febrile with a leukocytosis. (See 'Complicated choledocholithiasis' above.)
● Patients suspected of having choledocholithiasis are diagnosed with a combination of laboratory tests and
imaging studies. The first imaging study obtained is typically a transabdominal ultrasound. The results of
laboratory testing and transabdominal ultrasound are then used to stratify a patient as high risk, intermediate
risk, or low risk for having choledocholithiasis (algorithm 1). (See 'Diagnosis' above and 'Risk assessment'
above.)
• Patients at high risk for having common bile duct stones and with intact gallbladder generally proceed to
endoscopic retrograde cholangiopancreatography (ERCP) with stone removal, followed by elective
cholecystectomy, or they undergo cholecystectomy with intraoperative cholangiography, followed by
intraoperative or postoperative ERCP; where available, laparoscopic common duct exploration can be
performed. Precholecystectomy ERCP with postponed cholecystectomy is appropriate in patients with
acute cholangitis, in those with ongoing evidence of biliary obstruction and acute pancreatitis, and in
patients who are poor surgical candidates.
• Patients at intermediate risk either undergo preoperative endoscopic ultrasound or magnetic resonance
cholangiopancreatography, or they proceed to laparoscopic cholecystectomy with intraoperative
cholangiography or ultrasonography. Subsequent management choices are as above.
• Patients at low risk can proceed directly to cholecystectomy without additional testing, provided
gallstones or sludge were seen on preoperative imaging.
Use of UpToDate is subject to the Subscription and License Agreement.
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GRAPHICS
Flow chart for the evaluation and management of
choledocholithiasis
CBD: common bile duct; ERCP: endoscopic retrograde cholangiopancreatography; EUS: endoscopic
ultrasound; IOC: intraoperative cholangiogram; MRCP: magnetic resonance
cholangiopancreatography.
Reproduced from: ASGE Standards of Practice Committee. The role of endoscopy in the evaluation of
suspected choledocholithiasis. Gastrointest Endosc 2010; 71:1. Copyright © 2010. Illustration used
with the permission of Elsevier Inc. All rights reserved.
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Advantages and disadvantages associated with MRCP and EUS for the evaluation of
choledocholithiasis
MRCP
Advantages
Noninvasive
Intravenous contrast usually given but not required
Established technique, widely available
Disadvantages
Time consuming
Contraindications such as cardiac pacemaker/defibrillator, intracranial metal clips
Falsepositive studies (eg, intraductal artifacts such as air or blood, image reconstruction artifacts, motion artifacts)
Falsenegative studies (eg, stones in dilated CBD or stones <5 mm in the distal duct may not be visualized well)
EUS
Advantages
Very high resolution (0.1 mm) compared with MRCP (1.5 mm)
Dynamic imaging allowing manipulation and magnification of image for better visualization
ERCP can potentially be performed in the same setting for stone removal
Can be performed at the bedside in critically ill patients
Disadvantages
More invasive than MRCP
Need for sedation
Risks associated with sedation (eg, cardiopulmonary compromise) and endoscopy (eg, bleeding and perforation)
Limited availability of equipment and trained endosonographers
Not possible or limited role in altered anatomy (eg, pyloric stenosis, RouxenY bypass)
CBD: common bile duct; ERCP: endoscopic retrograde cholangiopancreatography; EUS: endoscopic ultrasound; MRCP:
magnetic endoscopic retrograde cholangiopancreatography.
Courtesy of ML Freeman, MD.
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Transabdominal ultrasound showing common bile duct
stones
A transverse ultrasound in the region of the porta hepatis shows multiple
shadowing stones (arrows) within a dilated distal common bile duct.
Courtesy of ML Freeman, MD.
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Common bile duct stone on endoscopic retrograde
cholangiopancreatography (ERCP)
Cholangiogram showing large (2 cm) common bile duct stone (arrow).
Courtesy of Martin L. Freeman, MD.
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Comparison of MRCP/ERCP and EUS for the detection of
common bile duct stones
Small bile duct stone missed by magnetic resonance cholangiopancreatography (MRCP)
and endoscopic retrograde cholangiopancreatography (ERCP), but shown by endoscopic
ultrasound (EUS). This demonstrates the superior sensitivity of EUS for small bile duct
stones. A) MRCP showing dilated bile duct with no apparent stone, incidental pancreas
divisum. B) EUS in same patient showing very small bile duct stone (<5 mm) (arrow).
C) ERCP in same patient showing dilated common bile duct without apparent stone. D)
Endoscopic view of extracted stone after biliary sphincterotomy (arrow).
Courtesy of ML Freeman, MD.
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Choledocholithiasis after RouxenY gastric bypass
Magnetic resonance cholangiopancreatography (MRCP) showing large distally
impacted bile duct stone in a patient post RouxenY gastric bypass with
jaundice.
Courtesy of ML Freeman, MD.
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Computed tomography scan showing a distal bile duct
stone
Courtesy of ML Freeman, MD.
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Classification of jaundice according to type of bile pigment and mechanism
Unconjugated hyperbilirubinemia Conjugated hyperbilirubinemia
Increased bilirubin production* (continued)
Extravascular hemolysis Extrahepatic cholestasis (biliary obstruction)
Extravasation of blood into tissues Choledocholithiasis
Intravascular hemolysis Intrinsic and extrinsic tumors (eg,
cholangiocarcinoma, pancreatic cancer)
Dyserythropoiesis
Primary sclerosing cholangitis
Wilson disease
AIDS cholangiopathy
Impaired hepatic bilirubin uptake
Acute and chronic pancreatitis
Heart failure
Strictures after invasive procedures
Portosystemic shunts
Certain parasitic infections (eg, Ascaris
Some patients with Gilbert syndrome lumbricoides, liver flukes)
Certain drugs ¶ rifampin, probenecid, flavaspadic Intrahepatic cholestasis
acid, bunamiodyl
Viral hepatitis
Impaired bilirubin conjugation
Alcoholic hepatitis
CriglerNajjar syndrome types I and II
Nonalcoholic steatohepatitis
Gilbert syndrome
Chronic hepatitis
Neonates
Primary biliary cholangitis
Hyperthyroidism
Drugs and toxins (eg, alkylated steroids,
Ethinyl estradiol chlorpromazine, herbal medications [eg, Jamaican
Liver diseases chronic hepatitis, advanced bush tea], arsenic)
cirrhosis Sepsis and hypoperfusion states
Conjugated hyperbilirubinemia Infiltrative diseases (eg, amyloidosis, lymphoma,
sarcoidosis, tuberculosis)
Defect of canalicular organic anion transport
Total parenteral nutrition
DubinJohnson syndrome
Postoperative cholestasis
Defect of sinusoidal reuptake of conjugated
bilirubin Following organ transplantation
Rotor syndrome Hepatic crisis in sickle cell disease
Pregnancy
Endstage liver disease
AIDS: acquired immunodeficiency syndrome.
* Serum bilirubin concentration usually less than 4 mg/dL (68 mmol/L) in the absence of underlying liver disease.
¶ The hyperbilirubinemia induced by drugs usually resolves within 48 hours after the drug is discontinued.
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