Diferencia entre revisiones de «Choledocholithiasis»
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==Background== | ==Background== | ||
*Occurs when stone expelled from gallbladder becomes impacted in the common bile duct | *Occurs when stone expelled from gallbladder becomes impacted in the common bile duct | ||
*If infected, becomes [[Cholangitis]] | *If infected, becomes [[Special:MyLanguage/Cholangitis|Cholangitis]] | ||
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{{Gallbladder background}} | {{Gallbladder background}} | ||
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{{Gallbladder disease types}} | {{Gallbladder disease types}} | ||
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==Clinical Features== | ==Clinical Features== | ||
*[[RUQ pain]] | |||
*[[Special:MyLanguage/RUQ pain|RUQ pain]] | |||
**Radiation to the right shoulder (phrenic nerve irritation) | **Radiation to the right shoulder (phrenic nerve irritation) | ||
**Early pain characterized as colicky, intermittent | **Early pain characterized as colicky, intermittent | ||
**Once impacted, is constant and severe | **Once impacted, is constant and severe | ||
*[[Nausea and Vomiting]] | *[[Special:MyLanguage/Nausea and Vomiting|Nausea and Vomiting]] | ||
*[[Jaundice]]/scleral icterus | *[[Special:MyLanguage/Jaundice|Jaundice]]/scleral icterus | ||
**Caused by buildup of direct bilirubin in blood | **Caused by buildup of direct bilirubin in blood | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
===[[Right upper quadrant abdominal pain|RUQ Pain]]=== | |||
*[[Gallbladder Disease (Main)|Gallbladder disease]] | |||
**[[Acute cholecystitis]] | ===[[Special:MyLanguage/Right upper quadrant abdominal pain|RUQ Pain]]=== | ||
**[[Cholangitis]] | |||
**[[Symptomatic cholelithiasis]]/[[Biliary Colic]] | *[[Special:MyLanguage/Gallbladder Disease (Main)|Gallbladder disease]] | ||
**[[Acalculous cholecystitis]] | **[[Special:MyLanguage/Acute cholecystitis|Acute cholecystitis]] | ||
**[[Gallstone pancreatitis]] | **[[Special:MyLanguage/Cholangitis|Cholangitis]] | ||
**[[Choledocholithiasis]] | **[[Special:MyLanguage/Symptomatic cholelithiasis|Symptomatic cholelithiasis]]/[[Special:MyLanguage/Biliary Colic|Biliary Colic]] | ||
*[[Peptic ulcer disease]] with or without perforation | **[[Special:MyLanguage/Acalculous cholecystitis|Acalculous cholecystitis]] | ||
*[[Pancreatitis]] | **[[Special:MyLanguage/Gallstone pancreatitis|Gallstone pancreatitis]] | ||
*[[Acute hepatitis]] | **[[Special:MyLanguage/Choledocholithiasis|Choledocholithiasis]] | ||
*[[Pyelonephritis]] | *[[Special:MyLanguage/Peptic ulcer disease|Peptic ulcer disease]] with or without perforation | ||
*[[Pneumonia]] | *[[Special:MyLanguage/Pancreatitis|Pancreatitis]] | ||
*[[Kidney stone]] | *[[Special:MyLanguage/Acute hepatitis|Acute hepatitis]] | ||
*[[GERD]] | *[[Special:MyLanguage/Pyelonephritis|Pyelonephritis]] | ||
*[[Appendicitis]] (retrocecal) | *[[Special:MyLanguage/Pneumonia|Pneumonia]] | ||
*[[Pyogenic liver abscess]] | *[[Special:MyLanguage/Kidney stone|Kidney stone]] | ||
*[[Fitz-Hugh-Curtis Syndrome]] | *[[Special:MyLanguage/GERD|GERD]] | ||
*Hepatomegaly due to [[CHF]] | *[[Special:MyLanguage/Appendicitis|Appendicitis]] (retrocecal) | ||
*[[Herpes zoster]] | *[[Special:MyLanguage/Pyogenic liver abscess|Pyogenic liver abscess]] | ||
*[[Myocardial ischemia]] | *[[Special:MyLanguage/Fitz-Hugh-Curtis Syndrome|Fitz-Hugh-Curtis Syndrome]] | ||
*[[Bowel obstruction]] | *Hepatomegaly due to [[Special:MyLanguage/CHF|CHF]] | ||
*[[Pulmonary embolism]] | *[[Special:MyLanguage/Herpes zoster|Herpes zoster]] | ||
*[[Abdominal aortic aneurysm]] | *[[Special:MyLanguage/Myocardial ischemia|Myocardial ischemia]] | ||
*[[Special:MyLanguage/Bowel obstruction|Bowel obstruction]] | |||
*[[Special:MyLanguage/Pulmonary embolism|Pulmonary embolism]] | |||
*[[Special:MyLanguage/Abdominal aortic aneurysm|Abdominal aortic aneurysm]] | |||
==Evaluation== | ==Evaluation== | ||
[[File:Ultrasonography of common bile duct stone, with arrow.jpg|thumb|RUQ ultrasound showing non-obstructing common bile duct stone.]] | [[File:Ultrasonography of common bile duct stone, with arrow.jpg|thumb|RUQ ultrasound showing non-obstructing common bile duct stone.]] | ||
*[[LFTs]], lipase, and basic chemistry | *[[Special:MyLanguage/LFTs|LFTs]], lipase, and basic chemistry | ||
*Imaging | *Imaging | ||
**[[RUQ Ultrasound]] | **[[Special:MyLanguage/RUQ Ultrasound|RUQ Ultrasound]] | ||
***Noninvasive and quick | ***Noninvasive and quick | ||
***Common bile duct < 6 mm plus 1mm per decade after 60 yrs old | ***Common bile duct < 6 mm plus 1mm per decade after 60 yrs old | ||
***US is highly sensitive and specific for [[acute cholecystitis]], much less sensitive/specific in identifying cholelithiasis due to exam limitations (i.e. difficulty identifying the CBD) | ***US is highly sensitive and specific for [[Special:MyLanguage/acute cholecystitis|acute cholecystitis]], much less sensitive/specific in identifying cholelithiasis due to exam limitations (i.e. difficulty identifying the CBD) | ||
**ERCP - highly sensitive and specific, also therapeutic | **ERCP - highly sensitive and specific, also therapeutic | ||
**MRCP - comparable sensitivity/specificity to ERCP | **MRCP - comparable sensitivity/specificity to ERCP | ||
**HIDA Scan - not useful, as IDA (technetium 99m-labeled iminodiacetic acid) can still go into gallbladder | **HIDA Scan - not useful, as IDA (technetium 99m-labeled iminodiacetic acid) can still go into gallbladder | ||
==Management== | ==Management== | ||
*[[Pain control]] | |||
*[[Fluid resuscitation]] and [[electrolyte repletion]] | *[[Special:MyLanguage/Pain control|Pain control]] | ||
*[[Special:MyLanguage/Fluid resuscitation|Fluid resuscitation]] and [[Special:MyLanguage/electrolyte repletion|electrolyte repletion]] | |||
*NPO | *NPO | ||
*If any concern for concomitant [[acute cholecystitis]], start antibiotics | *If any concern for concomitant [[Special:MyLanguage/acute cholecystitis|acute cholecystitis]], start antibiotics | ||
**Always consider [[cholangitis]] | **Always consider [[Special:MyLanguage/cholangitis|cholangitis]] | ||
==Disposition== | ==Disposition== | ||
*Admission to medical services | *Admission to medical services | ||
**Consult to GI for spherincerotomy and stone removal vs General Surgery for operative management | **Consult to GI for spherincerotomy and stone removal vs General Surgery for operative management | ||
**Strong predictors for choledocholithiasis on ERCP<ref>Magalhaes J et al. Endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis: From guidelines to clinical practice. Feb 2015. World J Gastrointest Endosc. 2015 Feb 16; 7(2): 128–134.</ref>: | **Strong predictors for choledocholithiasis on ERCP<ref>Magalhaes J et al. Endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis: From guidelines to clinical practice. Feb 2015. World J Gastrointest Endosc. 2015 Feb 16; 7(2): 128–134.</ref>: | ||
***Clinical ascending [[cholangitis]] | ***Clinical ascending [[Special:MyLanguage/cholangitis|cholangitis]] | ||
***CBD stones on US | ***CBD stones on US | ||
***Total bilirubin > 4 mg/dL | ***Total bilirubin > 4 mg/dL | ||
==See Also== | ==See Also== | ||
*[[Gallbladder disease (main)]] | |||
*[[Special:MyLanguage/Gallbladder disease (main)|Gallbladder disease (main)]] | |||
==External Links== | ==External Links== | ||
==References== | ==References== | ||
<references/> | <references/> | ||
[[Category:GI]] | [[Category:GI]] | ||
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Revisión del 21:47 4 ene 2026
Background
- Occurs when stone expelled from gallbladder becomes impacted in the common bile duct
- If infected, becomes Cholangitis
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Anatomy & Pathophysiology
- Gallstones are classified as cholesterol stones and pigmented stones (black and brown), and are present in approx 20% of females and 8% of males in the United States
- These stones cause the majority of all biliary tract problems, and depending on where the stone become impacted, specific problems occur.
- Bile flows out the gallbladder, down the cystic duct into the common bile duct, and ultimately into the 1st portion of the duodenum.
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Gallbladder disease types
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Bile duct and pancreas anatomy. 1. Bile ducts: 2. Intrahepatic bile ducts; 3. Left and right hepatic ducts; 4. Common hepatic duct; 5. Cystic duct; 6. Common bile duct; 7. Sphincter of Oddi; 8. Major duodenal papilla; 9. Gallbladder; 10-11. Right and left lobes of liver; 12. Spleen; 13. Esophagus; 14. Stomach; 15. Pancreas: 16. Accessory pancreatic duct; 17. Pancreatic duct; 18. Small intestine; 19. Duodenum; 20. Jejunum; 21-22: Right and left kidneys.
- Symptomatic cholelithiasis (biliary colic)
- Choledocholithiasis
- Acute calculous cholecystitis
- Ascending cholangitis
- Acalculous cholecystitis
- Biliary atresia
- Cholestasis of pregnancy
Clinical Features
- RUQ pain
- Radiation to the right shoulder (phrenic nerve irritation)
- Early pain characterized as colicky, intermittent
- Once impacted, is constant and severe
- Nausea and Vomiting
- Jaundice/scleral icterus
- Caused by buildup of direct bilirubin in blood
Differential Diagnosis
RUQ Pain
- Gallbladder disease
- Peptic ulcer disease with or without perforation
- Pancreatitis
- Acute hepatitis
- Pyelonephritis
- Pneumonia
- Kidney stone
- GERD
- Appendicitis (retrocecal)
- Pyogenic liver abscess
- Fitz-Hugh-Curtis Syndrome
- Hepatomegaly due to CHF
- Herpes zoster
- Myocardial ischemia
- Bowel obstruction
- Pulmonary embolism
- Abdominal aortic aneurysm
Evaluation
- LFTs, lipase, and basic chemistry
- Imaging
- RUQ Ultrasound
- Noninvasive and quick
- Common bile duct < 6 mm plus 1mm per decade after 60 yrs old
- US is highly sensitive and specific for acute cholecystitis, much less sensitive/specific in identifying cholelithiasis due to exam limitations (i.e. difficulty identifying the CBD)
- ERCP - highly sensitive and specific, also therapeutic
- MRCP - comparable sensitivity/specificity to ERCP
- HIDA Scan - not useful, as IDA (technetium 99m-labeled iminodiacetic acid) can still go into gallbladder
- RUQ Ultrasound
Management
- Pain control
- Fluid resuscitation and electrolyte repletion
- NPO
- If any concern for concomitant acute cholecystitis, start antibiotics
- Always consider cholangitis
Disposition
- Admission to medical services
- Consult to GI for spherincerotomy and stone removal vs General Surgery for operative management
- Strong predictors for choledocholithiasis on ERCP[1]:
- Clinical ascending cholangitis
- CBD stones on US
- Total bilirubin > 4 mg/dL
See Also
External Links
References
- ↑ Magalhaes J et al. Endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis: From guidelines to clinical practice. Feb 2015. World J Gastrointest Endosc. 2015 Feb 16; 7(2): 128–134.