Biliary Tract Disease: Biliary Tract Disease: Stones and Cholangitis

0:00Welcome to Board Pearls. This is episode three of four of the Biliary Tract Disease chapter, in the Pancreatic and Biliary Disease module. This episode is the bile duct stone and the infection it causes. The first patient is a man with biliary colic, abnormal liver tests, and a dilated duct, and his case shows how duct stones present, how the American Society for Gastrointestinal Endoscopy, ASGE, twenty nineteen system sets the probability of a stone and decides who goes to endoscopic retrograde cholangiopancreatography, ERCP, when endoscopic ultrasound, EUS, beats magnetic resonance cholangiopancreatography, MRCP, and why not everyone goes straight to ERCP. A frail woman shows when the gallbladder stays in after the duct is cleared. The second patient is a woman with fever and jaundice, and her case shows acute cholangitis: why antibiotics alone can't cure it, the Charcot triad and Reynolds pentad, the Tokyo grades and how fast to drain at each, why improvement on antibiotics doesn't cancel the ERCP, and which antibiotics to use. A man after gastric bypass shows what to do when ERCP can't reach the papilla.

1:10Here's the first patient. A fifty-nine-year-old man has had three hours of severe right upper quadrant pain, now easing, without fever. His alanine aminotransferase, ALT, is two hundred eighty, his alkaline phosphatase is twice normal, and his bilirubin is two point three, with a normal lipase. His ultrasound shows gallstones in the gallbladder and an eight-millimeter common bile duct without a visible duct stone.

1:34Biliary pain with cholestatic liver tests and a dilated duct suggests choledocholithiasis, a stone in the common bile duct, even though none is seen. Duct stones present as biliary colic with more pronounced liver enzyme rises than gallbladder stones alone, jaundice when obstruction is complete or prolonged, cholangitis when bacteria infect the obstructed duct, and gallstone pancreatitis when a stone impacts at the ampulla. His colic with these labs fits a stone passing through or sitting in his duct.

2:04How likely a stone is decides his next test. The ASGE twenty nineteen system has three levels. High probability, over fifty percent, needs one of three findings: a stone seen in the duct on imaging, clinical ascending cholangitis, or a bilirubin over four with a common bile duct wider than six millimeters in a patient with a gallbladder. Those patients go straight to ERCP, because the probability justifies the procedure's risk. Intermediate probability, ten to fifty percent, is any abnormal liver biochemistry, a dilated duct without a visible stone, or age over fifty-five, and those patients get MRCP or EUS first. Low probability, under ten percent, is none of those, and those patients go to laparoscopic cholecystectomy, with intraoperative cholangiography or laparoscopic ultrasound only if needed. He has no visible stone, no cholangitis, and a bilirubin under four, but he has abnormal liver tests, a dilated duct, and an age over fifty-five, so he's intermediate.

3:06The system exists to protect him from an unnecessary ERCP. ERCP has a complication rate of five to ten percent, mostly post-ERCP pancreatitis, so it's reserved for confirmed or highly likely obstruction. Even among high-probability patients, only seventy to eighty percent actually have a stone at ERCP, which is why some experts image even high-risk patients first, to avoid a complication from an empty procedure. A bilirubin over four with a dilated duct is fairly sensitive and specific in a patient with biliary pain, while a lower bilirubin or a raised transaminase alone is much less specific, so his ALT of two hundred eighty doesn't move him into the high group.

3:48As an intermediate-probability patient, he needs EUS or MRCP, and the choice depends on the stone that's suspected. MRCP has a sensitivity of about ninety percent overall but only about seventy percent for stones smaller than six millimeters, while EUS has a sensitivity of ninety-four percent and readily detects microlithiasis. So EUS is preferred when small stones or sludge are suspected, and MRCP when a non-invasive survey of the duct is acceptable. A small stone in a mildly dilated duct is what MRCP is most likely to miss, so he has EUS, which shows a four-millimeter stone in his distal duct. ERCP with sphincterotomy removes it, which succeeds in ninety to ninety-five percent of cases, and he goes on to laparoscopic cholecystectomy. A bilirubin of five point two with the same duct, or a stone seen on his ultrasound, would have sent him straight to ERCP. Normal liver tests, a normal duct, and an age of forty-two would have meant cholecystectomy alone.

4:50Had his stone been large, sphincterotomy alone might not have cleared it. Stones of one centimeter or more fail sphincterotomy alone in about ten to fifteen percent, because a sphincterotomy can only safely enlarge the papilla to the width of the bile duct inside the duodenal wall, and cutting further risks perforation or major bleeding. For those stones, ASGE guidance recommends either sphincterotomy plus large-balloon dilation, which stretches the opening without more cutting, or cholangioscopy-directed electrohydraulic or laser lithotripsy, which breaks the stone under direct view. Mechanical basket lithotripsy can also fragment stones but carries a higher risk of impaction with very large ones. The techniques are covered in chapter twenty-nine.

5:34His presentation also shows when ERCP is the wrong move. In gallstone pancreatitis without ongoing obstruction or cholangitis, ERCP is avoided and cholecystectomy is done during the same admission, because the offending stone has usually already passed, and an empty ERCP exposes the patient to pancreatitis risk for nothing. And the timing of a stone after cholecystectomy points to its origin. Stones found less than two years after cholecystectomy are usually retained from the original gallbladder, while those found later are usually new brown pigment stones, formed in the duct from stasis and bacterial deconjugation.

6:12After his duct is cleared, his gallbladder comes out, but not every patient's does. An eighty-seven-year-old woman with severe heart failure and dementia has had a duct stone removed, with stones still in her gallbladder, and she's a very poor surgical candidate. After extraction, residual gallbladder stones cause symptoms in about ten percent a year, around thirty percent at five years, and that risk is weighed against the operation. With her high operative risk and limited life expectancy, her gallbladder stays in. For the fit fifty-nine-year-old, the same risk means his gallbladder comes out.

6:45A stone that blocks the duct can also infect it, and the second patient shows what that looks like. A seventy-eight-year-old woman with known gallstones has two days of right upper quadrant pain, rigors, and yellow eyes. Her temperature is thirty-nine point four, her heart rate one hundred eight, and her blood pressure one hundred ten over seventy. She's alert and oriented. Her white count is sixteen thousand and her bilirubin five point eight, with a normal albumin, creatinine, international normalized ratio, INR, and platelets. Her ultrasound shows an eleven-millimeter common bile duct with a distal stone.

7:21Fever, jaundice, and right upper quadrant pain with a duct stone is acute cholangitis, ascending bacterial infection of an obstructed biliary tree. It most often comes from duct stones, but also from cancer, an anastomotic stricture, or an occluded stent. Stagnant bile becomes colonized by enteric organisms, and raised pressure in the duct forces bacteria and endotoxin into the hepatic sinusoids, called cholangiovenous reflux, causing bacteremia, sepsis, and organ failure. Antibiotics can't sterilize a closed, obstructed space, so decompression is the treatment, and antibiotics buy time until it happens.

8:00Her symptoms fit the classic triad, but the triad's absence wouldn't have excluded the diagnosis. The Charcot triad, right upper quadrant pain, fever, and jaundice, is present in about seventy percent of cases at most, and in fifty to seventy percent in some series. The Reynolds pentad adds altered mental status and hypotension, and it marks severe disease. She has the triad, but not the pentad.

8:27Her severity sets how fast she's drained, because each level of organ stress shortens the time before she can't tolerate the procedure. The Tokyo Guidelines twenty eighteen define grade three, severe, as any organ dysfunction: cardiovascular dysfunction needing vasopressors, neurologic dysfunction, respiratory dysfunction with a ratio of arterial oxygen pressure to inspired oxygen fraction under three hundred, renal dysfunction with a creatinine above two, hepatic dysfunction with an INR above one point five, or hematologic dysfunction with platelets under one hundred thousand. Grade two, moderate, is any two of a white count over twelve thousand or under four thousand, a temperature of thirty-nine or higher, age seventy-five or older, a bilirubin over five, or an albumin under seven-tenths of the lower limit of normal. Grade one, mild, is the rest. She has no organ dysfunction but four of the grade two criteria, so she's grade two. No single criterion looks dramatic in her; the count decides. A sixty-five-year-old with a temperature of thirty-eight point two, a white count of eleven thousand, and a bilirubin of three would be grade one.

9:36Her grade sets the clock. Grade three needs ERCP within twenty-four hours, grade two within forty-eight hours, or sooner if septic shock develops, and grade one is drained electively once stones are confirmed, during the admission. An ASGE twenty twenty-one systematic review found that ERCP within forty-eight hours halves inpatient mortality and shortens the hospital stay compared with later ERCP, whatever the response to antibiotics. Clinical cholangitis is itself a high-probability criterion for a duct stone, and her stone is visible, so she goes straight to ERCP without MRCP or EUS.

10:19Her improvement on antibiotics doesn't change that plan. After a night of antibiotics and fluids, her fever is gone and her heart rate is eighty-four, and her team asks whether ERCP can wait. A patient whose vital signs normalize still needs ERCP within forty-eight hours, because clinical stability doesn't mean the obstruction has resolved, and infection is highly likely to return once antibiotics stop suppressing it. She has ERCP with sphincterotomy and stone removal on day two, and cholecystectomy is considered after she recovers. If she'd become hypotensive overnight, needing norepinephrine, and confused, that would be the Reynolds pentad and grade three, needing ERCP within twenty-four hours with intensive care support.

11:00Her antibiotics bridge her to drainage, and they're chosen for the bowel flora that infect the duct. Empiric coverage targets enteric gram-negatives and anaerobes, with a third-generation cephalosporin plus metronidazole, or piperacillin-tazobactam. A carbapenem is used for healthcare-associated infection, immunocompromise, or recent biliary instrumentation, such as cholangitis from a stent placed three weeks earlier. Coverage is narrowed once blood and bile cultures return. She starts ceftriaxone and metronidazole, her blood cultures grow E. coli, and her coverage is narrowed.

11:36Sometimes the papilla can't be reached, and the deadline still applies. A sixty-one-year-old man with a Roux-en-Y gastric bypass eight years ago has fever, jaundice, right upper quadrant pain, and a stone in a dilated duct on MRCP, which makes him grade two. When ERCP fails or the anatomy makes it impossible, EUS-guided biliary drainage or percutaneous transhepatic cholangiography provides rescue within the same window, as chapter twenty-nine covers. Recurrent cholangitis without stones raises a dominant stricture from primary sclerosing cholangitis or immunoglobulin G4-related sclerosing cholangitis, covered in chapter twenty, and a malignant obstruction is drained by the same rules, with the cause deciding what comes after.

12:22Here are the traps the boards set in duct stones. An intermediate-probability patient isn't sent straight to ERCP. A raised ALT alone doesn't make a patient high probability. Age over fifty-five is an intermediate-probability criterion. MRCP isn't the best test when a small stone is suspected. Even high-probability patients may have an empty duct. A stone over one centimeter needs more than sphincterotomy alone. ERCP isn't done in gallstone pancreatitis without obstruction or cholangitis. A stone found years after cholecystectomy is usually new, not retained. And a frail patient's gallbladder isn't removed by reflex after extraction.

13:04For cholangitis, the traps are these. Antibiotics alone don't treat it. An incomplete Charcot triad doesn't exclude it. Grade two can be reached without any single severe criterion, and age seventy-five counts. Grade two needs ERCP within forty-eight hours, and grade three within twenty-four. Improvement on antibiotics doesn't cancel the ERCP. Coverage is broadened after instrumentation. And EUS-guided or percutaneous drainage is the answer when anatomy blocks ERCP.

13:36So, start to finish. Stratify suspected duct stones by ASGE twenty nineteen: high probability goes to ERCP, intermediate probability goes to EUS or MRCP first, with EUS better for stones under six millimeters, and low probability goes to cholecystectomy with intraoperative imaging as needed. Add large-balloon dilation or cholangioscopic lithotripsy for stones of one centimeter or more. Stones found more than two years after cholecystectomy are usually new brown pigment stones. In poor surgical candidates, residual gallbladder stones cause symptoms in about ten percent a year.

14:17Cholangitis is an obstructed, infected duct that antibiotics can't sterilize. Grade it by Tokyo twenty eighteen, and drain grade three within twenty-four hours and grade two within forty-eight, even after improvement on antibiotics. Cover gram-negatives and anaerobes, with a carbapenem after instrumentation, in healthcare-associated infection, or with immunocompromise. When ERCP can't reach the papilla, use EUS-guided or percutaneous drainage.

14:45Episode four is biliary pain without stones, biliary cysts, bile leaks, and strictures.

14:52For the full chapter, the practice vignettes, and the topic-tagged question bank, head to board pearls dot com. You'll find the rest of the series on Apple Podcasts, Spotify, or wherever you listen to podcasts. That brings us to the end of episode three of four of chapter twenty-seven, and I'll see you in the next one.