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Choledocholithiasis

What's new

Updated 2024 SAGES guidelines for the management of choledocholithiasis during pregnancy.

Background

Overview

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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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of choledocholithiasis are prepared by our editorial team based on guidelines from the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES 2024), the Danish Surgical Society (DSS 2022), the World Society of Emergency Surgery (WSES 2020), the American College of Radiology (ACR 2019), the American Society for Gastrointestinal Endoscopy (ASGE 2019,2015,2011), ...
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Classification and risk stratification

Risk stratification: as per WSES 2020 guidelines, 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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Modified ASGE/SAGES criteria for stratification of common bile duct stones
Age (years)
> 55
Imaging findings
Evidence of common bile duct stone on abdominal ultrasound
Common bile duct diameter > 6 mm (with gallbladder in situ)
Laboratory findings
Total serum bilirubin level > 1.8 mg/dL
Abnormal liver biochemical test other than bilirubin
Complications
Ascending cholangitis
Clinical gallstone pancreatitis
Risk of common bile duct stone is low
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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

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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Medical management

UDCA: as per ASGE 2011 guidelines, consider initiating ursedeoxycholic acid as an adjunct to biliary stenting in the management of difficult stones.
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  • Antibiotic prophylaxis

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

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

Specific circumstances

Pregnant patients: as per SAGES 2024 guidelines, consider performing laparoscopic cholecystectomy over offering nonoperative management for the management of biliary disease during pregnancy.
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  • Patients with acute cholangitis

  • Patients with gallstone pancreatitis

  • Patients with Mirizzi syndrome

  • Patients with hepatolithiasis

  • Patients with reconstructed digestive tracts

Follow-up and surveillance

Management of recurrent stones: as per ASGE 2011 guidelines, manage recurrent common bile duct stones with repeat ERCP.
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