Choledocholithiasis

Background

The biliary system includes the hepatic bile canaliculi, intrahepatic ducts, extrahepatic ducts, the gall bladder, the cystic duct, and the common bile duct. The liver produces bile, which is not only a byproduct of red blood cell breakdown, but also aids in digestion. The gallbladder stores bile until stimulated, upon which bile flows out the gallbladder, down the cystic duct into the common bile duct, and ultimately into the 1st portion of the duodenum. 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. It is these stones that cause the majority of all biliary tract problems, and depending on where the stone become impacted, specific problems occur. Choledocholithiasis occurs when a stone is expelled out of the gallbladder and becomes impacted in the common bile duct.

Clinical Features

RUQ pain - early pain characterized as colicky (intermittent, comes and goes), once impacted, is constant and severe Nausea and Vomiting Radiation to the Right shoulder - phrenic nerve irritation Jaundice and Scleral icterus - caused by build up of direct bilirubin in blood

Differential Diagnosis

RUQ Pain

• Gallbladder disease
  • Acute cholecystitis
  • Cholangitis
  • Symptomatic cholelithiasis/Biliary Colic
  • Acalculous cholecystitis
  • Gallstone Pancreatitis
• 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

Labs

• Particularly LFTs, Lipase, and Basic Chemistry

Imaging

• Ultrasound of RUQ
  • Noninvasive and quick
  • Common bile duct < 4 mm plus 1mm per decade after 40 yrs old
  • While UTZ is highly sensitive and specific for acute cholecystitis, it lacks this in identifying cholelithiasis secondary to exam limitations (i.e. difficulty identifying the CBD)
• ERCP - highly sensitive and specific, also therapeutic
• MRCP - comparable to ERCP in Sn/Sp
• HIDA Scan - not useful, as IDA (technetium 99m-labeled iminodiacetic acid) can still go into gallbladder

Management

• Pain relief
• Fluid 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

References

Authors

Andy Gausepohl, Michael O'Brien, MD