Choledocholithiasis
Choledocholithiasis is a gallstone that has migrated into the common bile duct, causing obstructive jaundice and cholestatic liver chemistries and predisposing to acute cholangitis and gallstone pancreatitis. Risk is stratified by ASGE criteria and confirmed by MRCP, endoscopic ultrasound, or therapeutic ERCP, which clears the duct before same-admission cholecystectomy.
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What this article covers
- Overview
Definition: choledocholithiasis is the presence of a gallstone within the common bile duct, most often a stone that formed in the gallbladder and migrated through the cystic duct, obstructing bile flow.
- Epidemiology
Gallstone prevalence drives incidence: cholesterol stones are the most common type, and choledocholithiasis develops in a meaningful minority of patients with cholelithiasis as a stone migrates into the CBD.
- Risk factors
Known cholelithiasis: gallstones in the gallbladder are the prerequisite for a stone to migrate into the CBD (Cholelithiasis).
- Pathophysiology
Stone migration is the initiating event: a gallstone passes from the gallbladder through the cystic duct into the CBD, most often a cholesterol stone but sometimes a pigment stone from hemolysis or cirrhosis.
- Clinical features
Episodic postprandial RUQ pain: biliary-type pain, often triggered by fatty meals, that may be colicky and can radiate to the right shoulder or back.
- Differential diagnosis
Acute cholangitis: choledocholithiasis plus fever, systemic inflammation, and often hypotension or confusion in severe disease; a life-threatening infection of the obstructed duct that requires…
- Diagnosis
The diagnosis is confirmed by direct visualization of a stone in the common bile duct, either non-invasively on MRCP or EUS, or invasively and therapeutically at ERCP; ASGE probability criteria…
- Management
Provide symptomatic care first: IV fluids and pain control while risk stratification proceeds; keep the patient nil by mouth if intervention is anticipated within hours.
- Complications
Acute cholangitis: bacterial superinfection of the obstructed duct, presenting with the Charcot triad and capable of rapid progression to septic shock; the most urgent complication (acute cholangitis).
- Prognosis
Favorable with timely duct clearance: most patients recover fully once the stone is extracted and the gallbladder removed, with recurrence uncommon after complete stone clearance and cholecystectomy.
- Prevention
Same-admission cholecystectomy after ERCP stone extraction: removing the gallbladder within about 2 weeks of stone clearance (same hospitalization when cholangitis was present) prevents recurrent…
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Related articles
- Acute cholangitis
Acute cholangitis is a bacterial infection of an obstructed biliary tree, classically presenting as Charcot triad of fever, right upper quadrant pain, and jaundice and progressing to septic shock when drainage is delayed. Diagnosis follows the Tokyo Guidelines and severity grade, and treatment combines prompt broad-spectrum antibiotics with biliary drainage, most often by ERCP.
- Cholelithiasis
Cholelithiasis is the presence of gallstones in the gallbladder, most often cholesterol stones from bile supersaturation, and is asymptomatic in most patients. Symptomatic disease presents as biliary colic, self-limited postprandial right upper quadrant pain without fever, diagnosed by right upper quadrant ultrasound and treated with elective laparoscopic cholecystectomy.
- Acute cholecystitis
Acute cholecystitis is inflammation of the gallbladder from cystic duct obstruction, most often by a gallstone, presenting with RUQ pain lasting more than 6 hours, fever, and a positive Murphy sign. Diagnosis follows the Tokyo Guidelines TG18 criteria and severity grade, and treatment combines IV antibiotics with early laparoscopic cholecystectomy, or cholecystostomy in patients too unstable for surgery.
- Acute pancreatitis
Acute pancreatitis is acinar-cell autodigestion and inflammation of the pancreas, most often from gallstones or alcohol, diagnosed by the revised Atlanta criteria and graded mild, moderately severe, or severe by organ failure. Management centers on early goal-directed lactated Ringer's resuscitation, analgesia, early enteral feeding, and timed ERCP for gallstone pancreatitis with cholangitis, reserving antibiotics for confirmed infected necrosis.