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Choledocholithiasis

Definition
Choledocholithiasis is the presence of stones within the common bile duct, characterized by RUQ pain, nausea, and vomiting.
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Pathophysiology
Choledocholithiasis is caused by biliary stones, which can be divided into cholesterol (> 70% cholesterol), mixed (30-70% cholesterol), and pigmented (< 30% cholesterol) stones.
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Disease course
Choledocholithiasis causes clinical manifestations of RUQ pain, nausea, vomiting. Disease complications include jaundice, acute pancreatitis, and acute cholangitis.
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Prognosis and risk of recurrence
Percutaneous biliary stone procedures in choledocholithiasis are associated with a mortality rate of 1.4%.
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Key sources
The following summarized guidelines for the evaluation and management of choledocholithiasis are prepared by our editorial team based on guidelines from the Danish Surgical Society (DSS 2022), the World Society of Emergency Surgery (WSES 2020), the American Society for Gastrointestinal Endoscopy (ASGE 2019; 2015; 2011), the American College of Radiology (ACR 2019), the British Society of Gastroenterology (BSG 2017), and the European Association for the Study of the Liver (EASL 2016).
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Guidelines

1.Classification and risk stratification

Risk stratification: consider stratifying the risk of common bile duct stones according to the proposed classification modified from the ASGE and the SAGES guidelines.
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2.Diagnostic investigations

Initial evaluation: as per WSES 2020 guidelines, obtain liver function tests (including ALT, AST, GGT, bilirubin, and ALP) and abdominal ultrasound to assess the risk of choledocholithiasis in patients with acute calculous cholecystitis.
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  • MRCP/EUS

  • ERCP

3.Diagnostic procedures

Intraoperative cholangiography/laparoscopic ultrasound
As per WSES 2020 guidelines:
Obtain intraoperative cholangiography or laparoscopic ultrasound, or preoperative imaging (with MRCP or EUS), depending on local expertise and availability, in patients with acute calculous cholecystitis and moderate risk for choledocholithiasis.
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Obtain intraoperative cholangiography or laparoscopic ultrasound, or preoperative ERCP, depending on the local expertise and the availability of the technique, in patients at high risk for common bile duct stones.
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4.Medical management

Ursodeoxycholic acid: consider initiating ursedeoxycholic acid as an adjunct to biliary stenting in the management of difficult stones.
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  • Antibiotic prophylaxis

5.Therapeutic procedures

Stone removal: as per WSES 2020 guidelines, remove common bile duct stones, either preoperatively, intraoperatively, or postoperatively, according to the local expertise and the availability of several techniques.
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  • Endoscopic sphincterotomy

  • Biliary stenting

  • Endoscopic papillary balloon dilation

  • Percutaneous and EUS-guided approaches

  • Peroral approaches

6.Surgical interventions

Cholecystectomy
As per DSS 2022 guidelines:
Perform laparoscopic cholecystectomy combined with laparoscopic or endoscopic retrograde cholangiography-assisted common bile duct stone removal as a one-step procedure rather than a two-step procedure in patients with imaging confirmed choledocholithiasis.
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Consider performing laparoscopic cholecystectomy in addition to common bile duct stone removal in high-risk patients with choledocholithiasis.
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  • Laparoscopic common bile duct exploration

7.Specific circumstances

Patients with acute cholangitis: as per BSG 2017 guidelines, perform urgent biliary decompression (endoscopic common bile duct stone extraction and/or biliary stenting) in patients with acute cholangitis not responding to antibiotic therapy or having signs of septic shock. Consider performing percutaneous radiological drainage as an alternative if ERCP is not possible.
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  • Patients with gallstone pancreatitis

  • Patients with Mirizzi syndrome

  • Patients with hepatolithiasis

  • Patients with reconstructed digestive tracts

8.Follow-up and surveillance

Management of recurrent stones: manage recurrent common bile duct stones with repeat ERCP.
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