CHOLEDOCHOLITHIASIS

Passage of gallstones into the CBD occurs in ~1015% of patients with cholelithiasis. The
incidence of common duct stones increases with increasing age of the patient, so that up to 25% of
elderly patients may have calculi in the common duct. The overwhelming majority of bile duct stones
are cholesterol stones formed in the gallbladder, which then migrate into the extrahepatic biliary tree
through the cystic duct. Primary calculi arising de novo in the ducts are usually pigment stones
developing in patients with (1) hepatobiliary parasitism or chronic, recurrent cholangitis; (2) congenital
anomalies of the bile ducts (especially Caroli's disease); (3) dilated, sclerosed, or strictured ducts; or (4)
an MDR3 gene defect leading to impaired biliary phospholipids secretion. Common duct stones may
remain asymptomatic for years, may pass spontaneously into the duodenum, or (most often) may
present with biliary colic or a complication.
Complications
Cholangitis
Cholangitis may be acute or chronic, and symptoms result from inflammation, which usually is
caused by at least partial obstruction to the flow of bile. Bacteria are present on bile culture in ~75% of
patients with acute cholangitis early in the symptomatic course. The characteristic presentation of
acute cholangitis involves biliary pain, jaundice, and spiking fevers with chills (Charcot's triad). Blood
cultures are frequently positive, and leukocytosis is typical.
Nonsuppurative acute cholangitis is most common and may respond relatively rapidly to supportive
measures and to treatment with antibiotics. In suppurative acute cholangitis, however, the presence of
pus under pressure in a completely obstructed ductal system leads to symptoms of severe toxicity
mental confusion, bacteremia, and septic shock. Response to antibiotics alone in this setting is
relatively poor, multiple hepatic abscesses are often present, and the mortality rate approaches 100%
unless prompt endoscopic or surgical relief of the obstruction and drainage of infected bile are carried
out. Endoscopic management of bacterial cholangitis is as effective as surgical intervention. ERCP with
endoscopic sphincterotomy is safe and the preferred initial procedure for both establishing a definitive
diagnosis and providing effective therapy.
Obstructive Jaundice
Gradual obstruction of the CBD over a period of weeks or months usually leads to initial
manifestations of jaundice or pruritus without associated symptoms of biliary colic or cholangitis.
Painless jaundice may occur in patients with choledocholithiasis, but is much more characteristic of
biliary obstruction secondary to malignancy of the head of the pancreas, bile ducts, or ampulla of Vater.
In patients whose obstruction is secondary to choledocholithiasis, associated chronic calculous
cholecystitis is very common, and the gallbladder in this setting may be relatively indistensible. The
absence of a palpable gallbladder in most patients with biliary obstruction from duct stones is the basis
for Courvoisier's law, i.e., that the presence of a palpably enlarged gallbladder suggests that the biliary
obstruction is secondary to an underlying malignancy rather than to calculous disease. Biliary
obstruction causes progressive dilatation of the intrahepatic bile ducts as intrabiliary pressures rise.
CBD stones should be suspected in any patient with cholecystitis whose serum bilirubin level is
>85.5 mol/L (5 mg/dL). The maximum bilirubin level is seldom >256.5 mol/L (15.0 mg/dL) in patients
with choledocholithiasis unless concomitant hepatic disease or another factor leading to marked
hyperbilirubinemia exists. Serum bilirubin levels 342.0 mol/L (20 mg/dL) should suggest the
possibility of neoplastic obstruction. The serum alkaline phosphatase level is almost always elevated in
biliary obstruction. A rise in alkaline phosphatase often precedes clinical jaundice and may be the only
abnormality in routine liver function tests. There may be a two- to tenfold elevation of serum
aminotransferases, especially in association with acute obstruction. Following relief of the obstructing
process, serum aminotransferase elevations usually return rapidly to normal, while the serum bilirubin
level may take 12 weeks to return to normal. The alkaline phosphatase level usually falls slowly,
lagging behind the decrease in serum bilirubin. Hepatic bile flow is suppressed, and reabsorption and
regurgitation of conjugated bilirubin into the bloodstream lead to jaundice accompanied by dark urine
(bilirubinuria) and light-colored (acholic) stools.

Pancreatitis
The most common associated entity discovered in patients with nonalcoholic acute pancreatitis
is biliary tract disease. Biochemical evidence of pancreatic inflammation complicates acute
cholecystitis in 15% of cases and choledocholithiasis in >30%, and the common factor appears to be
the passage of gallstones through the common duct. Coexisting pancreatitis should be suspected in
patients with symptoms of cholecystitis who develop (1) back pain or pain to the left of the abdominal
midline, (2) prolonged vomiting with paralytic ileus, or (3) a pleural effusion, especially on the left side.
Surgical treatment of gallstone disease is usually associated with resolution of the pancreatitis.
Secondary Biliary Cirrhosis
Secondary biliary cirrhosis may complicate prolonged or intermittent duct obstruction with or
without recurrent cholangitis. Although this complication may be seen in patients with
choledocholithiasis, it is more common in cases of prolonged obstruction from stricture or neoplasm.
Once established, secondary biliary cirrhosis may be progressive even after correction of the
obstructing process, and increasingly severe hepatic cirrhosis may lead to portal hypertension or to
hepatic failure and death. Prolonged biliary obstruction may also be associated with clinically relevant
deficiencies of the fat-soluble vitamins A, D, E, and K.
Diagnosis and Treatment
The diagnosis of choledocholithiasis is usually made by cholangiography ,either preoperatively
by ERCP or intraoperatively at the time of cholecystectomy. When CBD stones are suspected prior to
laparoscopic cholecystectomy, preoperative ERCP with endoscopic papillotomy and stone extraction is
the preferred approach. It not only provides stone clearance but also defines the anatomy of the biliary
tree in relationship to the cystic duct. CBD stones should be suspected in gallstone patients who have
any of the following risk factors: (1) a history of jaundice or pancreatitis, (2) abnormal tests of liver
function, and (3) ultrasonographic evidence of a dilated CBD or stones in the duct. Alternatively, if
intraoperative cholangiography reveals retained stones, postoperative ERCP can be carried out. The
need for preoperative ERCP is expected to decrease further as laparoscopic techniques for bile duct
exploration improve.
The widespread use of laparoscopic cholecystectomy and ERCP has decreased the incidence of
complicated biliary tract disease and the need for choledocholithotomy and T-tube drainage of the bile
ducts. EBS followed by spontaneous passage or stone extraction is the treatment of choice in the
management of patients with common duct stones, especially in elderly or poor-risk patients.