Choledocholithiasis

Background

• Occurs when stone expelled from gallbladder becomes impacted in the common bile duct
• If infected, becomes Cholangitis

<translate>

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.

</translate>

Gallbladder disease types

Gallbladder anatomy (overview).

Gallbladder anatomy

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
  • Acute cholecystitis
  • Cholangitis
  • Symptomatic cholelithiasis/Biliary Colic
  • Acalculous cholecystitis
  • Gallstone pancreatitis
  • Choledocholithiasis
• 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 < 4 mm plus 1mm per decade after 40 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

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

See Also

• Gallbladder disease (main)