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Choledocholithiasis: Clinical manifestations, diagnosis, and management

Authors
Mustafa A Arain, MD
Martin L Freeman, MD
Section Editor
Douglas A Howell, MD, FASGE, FACG
Deputy Editor
Shilpa Grover, MD, MPH
All topics are updated as new evidence becomes available and our peer review
process is complete.
Literature review current through: Dec 2016. | This topic last updated: Mar 13,
2015.
INTRODUCTION Choledocholithiasis refers to the presence of gallstones within
the common bile duct. According to the National Health and Nutrition Examination
Survey (NHANES III), over 20 million Americans are estimated to have gallbladder
disease (defined as the presence of gallstones on transabdominal ultrasound or a
history of cholecystectomy) [1]. Among those with gallbladder disease, the exact
incidence and prevalence of choledocholithiasis are not known, but it has been
estimated that 5 to 20 percent of patients have choledocholithiasis at the time of
cholecystectomy, with the incidence increasing with age [2-8].

In Western countries, most cases of choledocholithiasis are secondary to the

passage of gallstones from the gallbladder into the common bile duct. Primary
choledocholithiasis (ie, formation of stones within the common bile duct) is less
common. Primary choledocholithiasis typically occurs in the setting of bile stasis
(eg, patients with cystic fibrosis), resulting in a higher propensity for intraductal
stone formation. Older adults with large bile ducts and periampullary diverticular
are at elevated risk for the formation of primary bile duct stones. Patients with
recurrent or persistent infection involving the biliary system are also at risk, a
phenomenon seen most commonly in populations from East Asia. (See "Recurrent
pyogenic cholangitis".)

The causes of primary choledocholithiasis often affect the biliary tract diffusely, so
patients may have both extrahepatic and intrahepatic biliary stones. Intrahepatic
stones may be complicated by recurrent pyogenic cholangitis.

This topic will review the clinical manifestations and diagnosis of

choledocholithiasis. The treatment of choledocholithiasis, as well as the
epidemiology and the general management of patients with gallstones, are
discussed separately:

(See "Endoscopic management of bile duct stones: Standard techniques and

mechanical lithotripsy".)

(See "Epidemiology of and risk factors for gallstones".)

(See "Approach to the patient with incidental gallstones".)

(See "Uncomplicated gallstone disease in adults".)

(See "Patient selection for the nonsurgical treatment of gallstone disease".)

(See "Dissolution therapy for the treatment of gallstones".)

CLINICAL MANIFESTATIONS Patients with choledocholithiasis typically

present with biliary-type pain and laboratory testing that reveals a cholestatic
pattern of liver test abnormalities (ie, elevated bilirubin and alkaline phosphatase).
Patients with uncomplicated choledocholithiasis are typically afebrile and have a
normal complete blood count and pancreatic enzyme levels. Occasionally, patients
are asymptomatic. In such patients, the diagnosis may be suspected because of
abnormal liver blood tests, abnormalities seen on imaging studies obtained for
unrelated reasons, or when an intraoperative cholangiogram obtained during
cholecystectomy suggests the presence of a common bile duct stone. (See
"Approach to the patient with abnormal liver biochemical and function tests",
section on 'Patterns of LFT abnormalities'.)

Complications of choledocholithiasis include acute pancreatitis and acute

cholangitis. Patients with acute pancreatitis typically have elevated serum
pancreatic enzyme levels, and patients with acute cholangitis are often febrile with
a leukocytosis. Rarely, patients with long-standing biliary obstruction develop
secondary biliary cirrhosis. (See 'Complicated choledocholithiasis' below.)

Uncomplicated choledocholithiasis

Symptoms Most patients with choledocholithiasis are symptomatic, although

occasional patients are asymptomatic. Symptoms associated with
choledocholithiasis include right upper quadrant or epigastric pain, nausea, and
vomiting. The pain is often more prolonged than is seen with typical biliary colic
(which typically resolves within six hours). (See "Uncomplicated gallstone disease
in adults", section on 'Biliary colic'.)

The pain from choledocholithiasis resolves when the stone either passes
spontaneously or is removed. Some patients have intermittent pain due to transient
blockage of the common bile duct. Transient blockage occurs when there is
retention and floating of stones or debris within the bile duct, a phenomenon
referred to as a "ball-valve" effect.

Physical examination On physical examination, patients with choledocholithiasis

often have right upper quadrant or epigastric tenderness. Patients may also appear
jaundiced. Courvoisier's sign (a palpable gallbladder on physical examination) may
be seen when gallbladder dilation develops because of an obstruction of the
common bile duct. It is more often associated with malignant common bile duct
obstruction, but has been reported with choledocholithiasis [9].

Laboratory tests Serum alanine aminotransferase (ALT) and aspartate

aminotransferase (AST) concentrations are typically elevated early in the course of
biliary obstruction. Later, liver tests are typically elevated in a cholestatic pattern,
with increases in serum bilirubin, alkaline phosphatase, and gamma-glutamyl
transpeptidase (GGT) exceeding the elevations in serum ALT and AST. (See
"Approach to the patient with abnormal liver biochemical and function tests",
section on 'Patterns of LFT abnormalities'.)
Studies have attempted to estimate the predictive value of liver chemistry tests for
choledocholithiasis [8,10-12]:

A meta-analysis of 22 studies evaluated the predictive role of multiple

examination findings and tests used in the diagnosis of choledocholithiasis,
including serum bilirubin and alkaline phosphatase [10]. An elevation in serum
bilirubin had a sensitivity of 69 percent and a specificity of 88 percent for
diagnosing a common bile duct stone. For elevations in serum alkaline
phosphatase, the values were 57 and 86 percent, respectively.

A study of 1002 patients who underwent laparoscopic cholecystectomy for

cholelithiasis evaluated five liver-related biochemical tests for predicting
choledocholithiasis: serum GGT, alkaline phosphatase, total bilirubin, ALT, and
AST [11]. The sensitivities ranged from 64 percent for AST to 84 percent for GGT,
and the specificities ranged from 68 percent for ALT to 88 percent for bilirubin.
Elevated serum GGT, alkaline phosphatase, and bilirubin levels were independent
predictors of a common bile duct stone on multivariable analysis (odds ratios of
3.2, 2.0, and 1.4, respectively).

Since liver tests may be elevated due to a wide variety of etiologies, the positive
predictive value of elevated liver tests is poor. On the other hand, the negative
predictive value of normal liver tests is high. Thus, normal liver tests play a greater
role in excluding choledocholithiasis than elevated liver tests play in diagnosing
stones.

Improving liver blood tests combined with symptom resolution suggests that a
patient with choledocholithiasis has spontaneously passed the gallstone.

Complicated choledocholithiasis The two major complications associated with

choledocholithiasis are pancreatitis and acute cholangitis. In addition to the
findings associated with uncomplicated choledocholithiasis, patients with biliary
pancreatitis typically present with nausea, vomiting, elevations in serum amylase
and lipase (by definition greater than three times the upper limit of
normal), and/or imaging findings suggestive of acute pancreatitis. (See "Clinical
manifestations and diagnosis of acute pancreatitis".)

Patients with acute cholangitis often present with Charcot's triad (fever, right upper
quadrant pain, and jaundice) and leukocytosis. In severe cases, bacteremia and
sepsis may lead to hypotension and altered mental status (Reynolds' pentad). (See
"Acute cholangitis", section on 'Clinical manifestations'.)

Long-standing biliary obstruction from various causes, including common bile duct
stones, may result in liver disease that may progress to cirrhosis, a phenomenon
referred to as secondary biliary cirrhosis [1,2]. Although rare in the setting of bile
duct stones, secondary biliary cirrhosis may eventually result in the same cirrhosis-
related complications that occur with other etiologies. Relief of biliary obstruction
has been shown to result in regression of liver fibrosis in patients with secondary
biliary cirrhosis in the setting of chronic pancreatitis and choledochal cysts [3,4]. It
is likely, but not known, whether stone removal results in similar improvement in
liver disease in patients with choledocholithiasis-induced secondary biliary
cirrhosis.
DIAGNOSIS Patients suspected of having choledocholithiasis are diagnosed with
a combination of laboratory tests and imaging studies. The first imaging study
obtained is typically a transabdominal ultrasound. Additional testing may include
magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasound
(EUS), and/or endoscopic retrograde cholangiopancreatography (ERCP).

The aim of the diagnostic evaluation is to confirm or exclude the presence of

common bile duct stones using the least invasive, most accurate, and most cost-
effective imaging modality [13]. The specific approach is determined by the level of
clinical suspicion, availability of imaging modalities, and patient factors (eg,
contraindications to a particular test) (algorithm 1). (See 'Diagnostic approach'
below.)

Diagnostic approach Patients are often suspected of having choledocholithiasis

when they present with right upper quadrant pain with elevated liver enzymes in a
primarily cholestatic pattern (disproportionate elevation of the alkaline
phosphatase, gamma-glutamyl transferase, and bilirubin). In a patient suspected of
having choledocholithiasis based on the history, physical exam, and laboratory
testing, we start by obtaining a transabdominal ultrasound. If not already done, we
also obtain a complete blood count to look for leukocytosis (which may suggest
acute cholangitis has developed) and pancreatic enzyme levels. (See
'Transabdominal ultrasound' below.)

We then use the results of laboratory tests and transabdominal ultrasound to

stratify a patient as high risk, intermediate risk, or low risk for having
choledocholithiasis. Subsequent management varies depending on the patient's
level of risk (algorithm 1) (see 'Risk assessment' below):

Patients at high risk proceed to ERCP with stone removal, followed by elective
cholecystectomy.

Patients at intermediate risk either undergo preoperative EUS or MRCP, or they

proceed to laparoscopic cholecystectomy with intraoperative cholangiography or
ultrasonography. If a stone is found preoperatively, patients should proceed to
ERCP with stone removal, followed by elective cholecystectomy, provided
gallstones or sludge were seen on preoperative imaging.

Patients at low risk can proceed directly to cholecystectomy without additional

testing, provided gallstones or sludge were seen on preoperative imaging.

Risk assessment In a [/external-

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cations_and_Products%2FPractice_Guidelines%2FPIIS0016510709025504.pdf&T
OPIC_ID=13922]2010 guideline, the American Society for Gastrointestinal
Endoscopy (ASGE) proposed the following approach to stratify patients based on
their probability of having choledocholithiasis. Patients were stratified using the
following predictors [14]:

"Very strong" predictors

The presence of a common bile duct stone on transabdominal ultrasound

Clinical acute cholangitis

A serum bilirubin greater than 4 mg/dL (68 micromol/L)

"Strong" predictors

A dilated common bile duct on ultrasound (more than 6 mm in a patient with a

gallbladder in situ)

A serum bilirubin of 1.8 to 4 mg/dL (31 to 68 micromol/L)

"Moderate" predictors

Abnormal liver biochemical test other than bilirubin

Age older than 55 years

Clinical gallstone pancreatitis

Using the above predictors, patients are stratified as:

High risk

At least one very strong predictor and/or

Both strong predictors

Intermediate risk

One strong predictor and/or

At least one moderate predictor

Low risk

No predictors

High-risk patients Patients categorized as being high risk for choledocholithiasis

have an estimated probability of having a common bile duct stone of >50 percent
[14]. In such patients, the appropriate first step in treatment is ERCP with removal
of any common bile duct stones, followed by elective cholecystectomy. (See
'Endoscopic retrograde cholangiopancreatography' below and "Endoscopic
management of bile duct stones: Standard techniques and mechanical lithotripsy".)

Intermediate-risk patients Intermediate-risk patients have an estimated 10 to 50

percent probability of having a common bile duct stone. Such patients require
evaluation to rule out choledocholithiasis, but the risk is not high enough to
warrant going directly to ERCP [14]. Less invasive options for detecting
choledocholithiasis include EUS and MRCP. Deciding which test should be
performed first depends on various factors such as ease of availability, cost, patient-
related factors, and the suspicion for a small stone (table 1). (See 'EUS and MRCP'
below.)

Because it is noninvasive, MRCP is often the first test performed to look for stones.
If positive, patients should undergo ERCP. In most cases, if the MRCP is negative
the patient can proceed to elective cholecystectomy (provided gallstones or biliary
sludge were demonstrated on preoperative imaging). However, if the MRCP is
negative, but the suspicion for a common bile duct stone remains moderate to high
(eg, in a patient whose laboratory tests are not improving), EUS is an appropriate
next step. In many centers, the endoscopist performing the EUS can perform an
ERCP during the same session if a stone is found.

An alternative to preoperative imaging is to proceed to laparoscopic

cholecystectomy with intraoperative cholangiography or ultrasonography, provided
a surgeon who is experienced with the techniques is available. This approach was
examined in a randomized trial with 100 patients at intermediate risk of having a
common bile duct stone [15]. Patients were assigned to either proceed directly to
laparoscopic cholecystectomy with intraoperative cholangiography or to initial EUS
followed by ERCP if positive, and subsequent laparoscopic cholecystectomy.
Patients who proceeded directly to surgery had a shorter median length of stay than
those who underwent EUS first (5 versus 8 days) and overall had fewer EUSs,
MRCPs, and ERCPs (25 versus 71). There were no differences between the groups
with regard to conversion to laparotomy, time in the operating room,
complications, or death. (See 'Intraoperative cholangiography' below and
'Intraoperative ultrasonography' below.)

Low-risk patients Low-risk patients are estimated to have a <10 percent

probability of having a common bile duct stone [14]. If gallstones or sludge are
present within the gallbladder on transabdominal ultrasound and the patient is a
good surgical candidate, the patient should proceed to cholecystectomy without
imaging of the common bile duct preoperatively or intraoperatively. Alternative
therapies, such as medical gallstone dissolution, may be considered for patients
who are not surgical candidates. (See "Dissolution therapy for the treatment of
gallstones".)

If there is no evidence of gallstones on imaging, alternative explanations for the

patient's pain should be sought. (See "Evaluation of the adult with abdominal
pain".)

Special circumstances

Concomitant acute pancreatitis Whether to proceed directly to ERCP in patients

with acute pancreatitis depends on whether the patient also has acute cholangitis.
Patients with both acute pancreatitis and acute cholangitis should undergo early
ERCP [14]. However, it is less clear if patients with acute pancreatitis without
cholangitis benefit from early ERCP [16]. Current evidence supports early ERCP in
patients with ongoing evidence of biliary obstruction, but it no longer supports
early ERCP in patients with severe pancreatitis alone [17].

In patients with acute pancreatitis but equivocal evidence of bile duct stones (eg,
improving liver enzyme tests and/or improvement or resolution of pain), MRCP or
EUS followed by ERCP only if the EUS/MRCP reveals a common bile duct stone is
an attractive option because it can detect common bile duct stones, but is not
associated with pancreatitis.

Issues related to ERCP in patients with acute biliary pancreatitis are discussed
elsewhere. (See "Management of acute pancreatitis", section on 'Endoscopic
retrograde cholangiopancreatography'.)
Prior cholecystectomy Choledocholithiasis will sometimes be suspected in a
patient who has previously undergone cholecystectomy. Choledocholithiasis can
occur in this setting if a gallstone escapes from the gallbladder during
cholecystectomy or if there is de novo stone formation within the common bile
duct. (See 'Introduction' above and "Laparoscopic cholecystectomy", section on
'Postcholecystectomy syndrome'.)

In such patients, transabdominal ultrasound is less helpful because a dilated

common bile duct seen on ultrasound may be the result of a common bile duct
stone, or it may be the result of the cholecystectomy. Following cholecystectomy,
the common bile duct may dilate to 10 mm. (See "Ultrasonography of the
hepatobiliary tract", section on 'Normal measurements on ultrasound'.)

One approach to patients who have undergone a prior cholecystectomy and who
present with biliary-type pain and liver test abnormalities, but in whom there is
uncertainty as to presence of a bile duct stone, is to proceed with an MRCP or EUS
to confirm the presence of a stone. If a stone is seen, proceeding with ERCP for
stone removal is the next step. If a stone is absent, then the patient may have
sphincter of Oddi dysfunction, and the approach to possible ERCP should be
modified to include specific informed consent regarding higher risk of ERCP in this
setting and the decreased benefit from sphincterotomy. In addition, the ERCP
techniques used should focus on risk reduction, with liberal use of protective
pancreatic stents [18] and consideration of rectal indomethacin [19]. (See
"Treatment of sphincter of Oddi dysfunction", section on 'Endoscopic
sphincterotomy' and "Prophylactic pancreatic stents to prevent ERCP-induced
pancreatitis: When do you use them?", section on 'Sphincter of Oddi dysfunction or
a small bile duct' and "Post-endoscopic retrograde cholangiopancreatography
(ERCP) pancreatitis", section on 'Nonsteroidal anti-inflammatory drugs'.)

Imaging test characteristics Several imaging modalities can be used for the
evaluation of patients with suspected choledocholithiasis, including:

Transabdominal ultrasound

ERCP

EUS

MRCP

Intraoperative cholangiography or ultrasonography

Transabdominal ultrasound The initial imaging study of choice in patients with

suspected common bile duct stones is a transabdominal ultrasound of the right
upper quadrant. Transabdominal ultrasound can evaluate for cholelithiasis,
choledocholithiasis, and common bile duct dilation. It is readily available,
noninvasive, permits bedside evaluation, and provides a low-cost means of
evaluating the common bile duct for stones. (See "Ultrasonography of the
hepatobiliary tract".)

The sensitivity of transabdominal ultrasound for choledocholithiasis ranges from

20 to 90 percent [14]. In a meta-analysis of five studies, the pooled sensitivity of
ultrasound for detecting a common bile duct stone was 73 percent, with a specificity
of 91 percent [20]. Transabdominal ultrasound has poor sensitivity for stones in the
distal common bile duct because the distal common bile duct is often obscured by
bowel gas in the imaging field [21-25]. Occasionally, a definite common bile duct
stone (one that casts a shadow) can be imaged by transabdominal ultrasound
(image 1).

A dilated common bile duct on transabdominal ultrasound is suggestive of, but not
specific for, choledocholithiasis [6,8,10]. A cutoff of 6 mm is often used to classify
a duct as being dilated [14]. However, using a cutoff of 6 mm may miss stones [26].
One study of 870 patients undergoing cholecystectomy found that stones were often
detected in patients whose ducts would have been classified as "nondilated" using
the 6 mm cutoff [27]. In addition, the probability of a stone in the common bile
duct increased with increasing common bile duct diameter:

0 to 4 mm: 3.9 percent

4.1 to 6 mm: 9.4 percent

6.1 to 8 mm: 28 percent

8.1 to 10 mm: 32 percent

>10 mm: 50 percent

Conversely, because the diameter of the common bile duct increases with age, older
adults may have a normal duct with a diameter that is >6 mm. (See
"Ultrasonography of the hepatobiliary tract", section on 'Normal measurements on
ultrasound'.)

Endoscopic retrograde cholangiopancreatography Traditionally, ERCP (image 2)

was used both as a diagnostic and therapeutic procedure in patients with suspected
choledocholithiasis. The sensitivity of ERCP for choledocholithiasis is estimated to
be 80 to 93 percent, with a specificity of 99 to 100 percent [28,29]. However,
ERCP is invasive, requires technical expertise, and is associated with complications
such as pancreatitis, bleeding, and perforation. As a result, ERCP is now reserved
for patients who are at high risk for having a common bile duct stone, particularly if
there if evidence of cholangitis, or who have had a stone demonstrated on other
imaging modalities. (See 'High-risk patients' above and "Endoscopic retrograde
cholangiopancreatography: Indications, patient preparation, and complications".)

EUS and MRCP EUS (image 3) and MRCP (picture 1) have largely replaced ERCP
for the diagnosis of choledocholithiasis in patients at intermediate risk for
choledocholithiasis. EUS is less invasive than ERCP, and MRCP is noninvasive.
Both tests are highly sensitive and specific for choledocholithiasis [30]. Deciding
which test should be performed first depends on various factors such as ease of
availability, cost, patient-related factors, and the suspicion for a small stone (table
1). (See 'Intermediate-risk patients' above and "Magnetic resonance
cholangiopancreatography" and "Endoscopic ultrasound in patients with suspected
choledocholithiasis".)

EUS and MRCP for the diagnosis of choledocholithiasis have been evaluated using
ERCP as the reference standard:
A meta-analysis of 27 studies with 2673 patients found that EUS had a sensitivity
of 94 percent and a specificity of 95 percent [31].

A review of 13 studies found that MRCP had a median sensitivity of 93 percent

and a median specificity of 94 percent [32].

Studies have prospectively compared the accuracy of EUS with MRCP in the
diagnosis of choledocholithiasis. These have been reviewed in two systemic reviews,
both of which showed no significant differences between the two modalities
[33,34]. In a pooled analysis of 301 patients from five randomized trials that
compared EUS with MRCP, there was no statistically significant difference in
aggregated sensitivity (93 versus 85 percent) or specificity (96 versus 93 percent).

MRCP is preferred for many patients because it is noninvasive. However, the

sensitivity of MRCP may be lower for small stones (<6 mm, (image 3)) [35], and
biliary sludge can be detected by EUS, but generally not by MRCP. As a result, EUS
should be considered in patients in whom the suspicion for choledocholithiasis
remains moderate to high despite a negative MRCP. (See 'Intermediate-risk
patients' above.)

Intraoperative cholangiography Intraoperative cholangiography has an estimated

sensitivity of 59 to 100 percent for diagnosing choledocholithiasis, with a specificity
of 93 to 100 percent [29,36,37]. However, it is highly operator-dependent and is
not routinely performed by many surgeons [38].

In the era prior to laparoscopic surgery, patients with gallstone disease and
suspected choledocholithiasis underwent open cholecystectomy including
cholangiography and palpation of the common bile duct and/or open exploration of
the common bile duct to diagnose and treat choledocholithiasis. As laparoscopic
surgery replaced open surgery as the preferred method for cholecystectomy,
exploration of the common bile duct for removal of intraductal stones became
technically more challenging. (See "Laparoscopic cholecystectomy", section on
'Evaluation for choledocholithiasis' and "Common bile duct exploration", section on
'Intraoperative cholangiography'.)

With improvements in cholangiography techniques and the use of fluoroscopic

rather than static cholangiography, the successful completion rate and accuracy of
intraoperative cholangiography have improved over time [39]. In practice, the use
of intraoperative cholangiography is highly operator-dependent and may be
technically unfeasible in patients with a severely inflamed gallbladder or with a tiny
or inflamed cystic duct.

Studies of intraoperative cholangiography during laparoscopic cholecystectomy

have shown the following:

In a review of 13 studies with 1980 patients undergoing laparoscopic

cholecystectomy, 9 percent had choledocholithiasis [36]. The success rate for
technical completion of intraoperative cholangiography ranged from 88 to 100
percent. Intraoperative cholangiography had a sensitivity of 68 to 100 percent and a
specificity of 92 to 100 percent for diagnosing choledocholithiasis.

In a more recent prospective population-based study, intraoperative

cholangiography was routinely attempted in 1171 patients undergoing
cholecystectomy [37]. The cholecystectomy was carried out laparoscopically in 79
percent. Intraoperative cholangiography was successful in 95 percent, and
choledocholithiasis was identified in 134 patients (11 percent). The sensitivity and
specificity of intraoperative cholangiography were 97 and 99 percent, respectively.

There is ongoing debate about the routine use of intraoperative cholangiography in

all patients undergoing laparoscopic cholecystectomy versus selective use in
patients at increased risk for intraductal stones, and practices vary widely among
surgeons. Proponents of routine intraoperative cholangiography argue that it
permits delineation of biliary anatomy, reduces and identifies bile duct injuries, and
identifies asymptomatic choledocholithiasis. Opponents argue that intraoperative
cholangiography adds to procedure time and expense. In addition, they argue that
asymptomatic common bile duct stones may pass spontaneously and/or have a low
potential for causing complications, such that their identification may lead to
unnecessary common bile duct exploration and/or conversion to open surgery [40-
50].

A 2008 study examined the frequency with which surgeons employ intraoperative
cholangiography. In the survey of 1417 surgeons, 27 percent defined themselves as
routine intraoperative cholangiography users [38]. Among the routine users, 91
percent reported using intraoperative cholangiography in more than 75 percent of
laparoscopic cholecystectomies. Academic surgeons were less often routine users
compared with nonacademic surgeons (15 versus 30 percent).

Intraoperative ultrasonography Another intraoperative approach for detecting

choledocholithiasis is intraoperative ultrasonography. During laparoscopy, an
ultrasound probe is inserted into the peritoneal cavity though a 10-mm trochar and
is used to scan the bile ducts. The reported sensitivity and specificity are over 90
percent, and it has been suggested that the routine use of intraoperative ultrasound
followed by selective intraoperative cholangiography leads to the accurate diagnosis
of choledocholithiasis, while reducing the need for intraoperative cholangiography
[51].

The use of intraoperative ultrasound may also decrease the rate of bile duct injury
[52]. Compared with intraoperative cholangiography, intraoperative ultrasound
does not require entry into the bile duct. However, it is associated with a longer
learning curve and is currently not as widely available [36]. The decision regarding
intraoperative cholangiography or intraoperative ultrasonography depends upon
patient selection and the surgeon's expertise and comfort with the techniques.

Other imaging modalities Abdominal computed tomography (CT) and

percutaneous cholangiopancreatography are alternative methods for diagnosing
choledocholithiasis. Unenhanced abdominal CT is neither sensitive nor specific for
choledocholithiasis. However, both sensitivity and specificity can be improved with
the use of intravenous contrast media combined with a helical cholangiography
protocol, increasing from 65 to 93 percent and from 84 to 100 percent, respectively
[53-58]. If a common bile duct stone is clearly visualized on CT (image 4), the
finding is highly specific. (See "Computed tomography of the hepatobiliary tract".)

Percutaneous transhepatic cholangiography is typically performed in patients who

are not candidates for ERCP, who have failed ERCP, who have surgically altered
anatomy preventing endoscopic access to the biliary tree, or who have intrahepatic
stones. Due to its invasive nature, it should generally be considered a therapeutic
procedure, rather than a diagnostic one. (See "Percutaneous transhepatic
cholangiography".)

DIFFERENTIAL DIAGNOSIS Patients with uncomplicated gallstone disease,

acute cholecystitis, sphincter of Oddi dysfunction, or functional gallbladder
disorder may all present with biliary colic, and patients with liver disease,
hematologic disorders, or biliary obstruction from any cause may present with
jaundice (table 2). Choledocholithiasis can typically be differentiated from these
other entities based on the patient's history, laboratory tests, and abdominal
imaging.

Patients with choledocholithiasis typically present acutely with prolonged episodes

of pain. On the other hand, the episodes of pain in patients with uncomplicated
gallstone disease, sphincter of Oddi dysfunction, or functional gallbladder disorder
typically last less than six hours and often occur intermittently. In addition,
patients with uncomplicated gallstone disease or functional gallbladder disorder
should have normal laboratory tests and imaging (though patients with sphincter of
Oddi dysfunction may have bile duct dilation and elevations in the alanine
aminotransferase, aspartate aminotransferase, and alkaline phosphatase that
normalize between attacks). Endoscopic ultrasound or magnetic resonance
cholangiopancreatography may be required to differentiate between sphincter of
Oddi dysfunction and choledocholithiasis. (See "Uncomplicated gallstone disease in
adults" and "Clinical manifestations and diagnosis of sphincter of Oddi
dysfunction" and "Functional gallbladder disorder in adults".)

Like patients with choledocholithiasis, patients with acute cholecystitis may have
prolonged episodes of pain that start suddenly. However, patients with acute
cholecystitis should not have a significantly elevated bilirubin or alkaline
phosphatase unless there is a secondary process causing cholestasis. In addition,
abdominal imaging in acute cholecystitis typically reveals a normal common bile
duct, gallbladder wall thickening, and a sonographic Murphy's sign. (See "Acute
cholecystitis: Pathogenesis, clinical features, and diagnosis".)

There are numerous causes of jaundice in addition to choledocholithiasis (table 2).

Choledocholithiasis is differentiated from these other conditions by the presence of
biliary-type pain and sometimes by a dilated common bile duct on abdominal
imaging. (See "Diagnostic approach to the adult with jaundice or asymptomatic
hyperbilirubinemia", section on 'Causes of hyperbilirubinemia'.)

MANAGEMENT The mainstay of the management of choledocholithiasis is

removal of the common bile duct stone either endoscopically or surgically. It is also
important to identify and treat the complications of choledocholithiasis, such as
acute pancreatitis and acute cholangitis. (See "Management of acute pancreatitis"
and "Acute cholangitis", section on 'Management'.)

The approach to stone removal depends on when the stone is discovered. If the
stone is detected before or after cholecystectomy, the stone should be removed with
endoscopic retrograde cholangiopancreatography (ERCP). (See "Endoscopic
management of bile duct stones: Standard techniques and mechanical lithotripsy".)

The choice of treatment for patients with choledocholithiasis found during surgery
includes intraoperative ERCP, intraoperative common bile duct exploration
(laparoscopic or open), and postoperative ERCP. At our center, intraoperative
ERCP is performed if consent was obtained preoperatively. Otherwise, ERCP is
performed at a later time during the same hospitalization, as is standard in most
practice settings. (See 'Intraoperative cholangiography' above and 'Intraoperative
ultrasonography' above.)

Intraoperative common bile duct exploration is performed selectively, based on

surgeon preference and local expertise. Open common bile duct exploration is more
widely available than laparoscopic common bile duct exploration but is associated
with significantly more complications [59]. In selected centers, laparoscopic
common bile duct exploration and stone removal is routinely performed. There are
relatively few indications for open common bile duct exploration, but
cholecystectomy in patients with surgically altered anatomy (eg, Roux-en-Y gastric
bypass) may be an example of an appropriate setting. (See "Common bile duct
exploration" and "Open cholecystectomy", section on 'Common bile duct
exploration'.)

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pieces are written in plain language, at the 5th to 6th grade reading level, and they
answer the four or five key questions a patient might have about a given condition.
These articles are best for patients who want a general overview and who prefer
short, easy-to-read materials. Beyond the Basics patient education pieces are
longer, more sophisticated, and more detailed. These articles are written at the
10th to 12th grade reading level and are best for patients who want in-depth
information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage
you to print or e-mail these topics to your patients. (You can also locate patient
education articles on a variety of subjects by searching on "patient info" and the
keyword(s) of interest.)

Beyond the Basics topics (see "Patient education: ERCP (endoscopic retrograde
cholangiopancreatography) (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Choledocholithiasis refers to the presence of gallstones within the common bile

duct. It has been estimated that 5 to 20 percent of patients with gallstones will have
choledocholithiasis at the time of cholecystectomy, with the incidence increasing
with age. (See 'Introduction' above.)

Most patients with choledocholithiasis are symptomatic, although occasional

patients are asymptomatic. Symptoms associated with choledocholithiasis include
right upper quadrant or epigastric pain, nausea, and vomiting. The pain is often
more prolonged than is seen with typical biliary colic (which typically resolves
within six hours). (See 'Symptoms' above.)

On physical examination, patients with choledocholithiasis often have right upper

quadrant or epigastric tenderness. Patients may also appear jaundiced. (See
'Physical examination' above.)

Serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) are

typically elevated early in the course of biliary obstruction. Later, liver tests are
typically elevated in a cholestatic pattern, with elevations in serum bilirubin,
alkaline phosphatase, and gamma-glutamyl transpeptidase (GGT) being more
pronounced than those in ALT and AST. (See 'Laboratory tests' above.)

Complications of choledocholithiasis include acute pancreatitis and acute

cholangitis. Patients with acute pancreatitis typically have elevated serum
pancreatic enzyme levels, and patients with acute cholangitis are often febrile with
a leukocytosis. (See 'Complicated choledocholithiasis' above.)

Patients suspected of having choledocholithiasis are diagnosed with a

combination of laboratory tests and imaging studies. The first imaging study
obtained is typically a transabdominal ultrasound. The results of laboratory testing
and transabdominal ultrasound are then used to stratify a patient as high risk,
intermediate risk, or low risk for having choledocholithiasis (algorithm 1) (See
'Diagnosis' above and 'Risk assessment' above.)

Patients at high risk for having common bile duct stones and with intact
gallbladder generally proceed to endoscopic retrograde cholangiopancreatography
(ERCP) with stone removal, followed by elective cholecystectomy, or they undergo
cholecystectomy with intraoperative cholangiography, followed by intraoperative or
postoperative ERCP; where available, laparoscopic common duct exploration can
be performed. Pre-cholecystectomy ERCP with postponed cholecystectomy is
appropriate in patients with acute cholangitis, in those with ongoing evidence of
biliary obstruction and acute pancreatitis, and in patients who are poor surgical
candidates.

Patients at intermediate risk either undergo preoperative endoscopic ultrasound or

magnetic resonance cholangiopancreatography, or they proceed to laparoscopic
cholecystectomy with intraoperative cholangiography or ultrasonography.
Subsequent management choices are as above.

Patients at low risk can proceed directly to cholecystectomy without additional

testing, provided gallstones or sludge were seen on preoperative imaging.