Etiology
In pts with cholelithiasis, passage of gallstones into CBD occurs in 10-15%; increases with age. At cholecystectomy, undetected stones are left behind in 1-5% of pts.
Symptoms and Signs
Choledocholithiasis may present as an incidental finding, biliary colic, obstructive jaundice, cholangitis, or pancreatitis. Cholangitis usually presents as fever, RUQ pain, and jaundice (Charcot's triad).
Laboratory
Elevations in serum bilirubin, alkaline phosphatase, and aminotransferases. Leukocytosis usually accompanies cholangitis; blood cultures are frequently positive. Biochemical evidence of pancreatic inflammation is seen in >30% of cases.
Imaging
Diagnosis usually made by cholangiography either preoperatively by endoscopic retrograde cholangiopancreatography (ERCP), magnetic resonance cholangiopancreatography (MRCP), or intraoperatively at the time of cholecystectomy. Ultrasonography may reveal dilated bile ducts but has poor visualization of the distal CBD (Table 153-1 Diagnostic Evaluation of the Bile Ducts).
Differential Diagnosis
Acute cholecystitis, renal colic, perforated viscus, pancreatitis.
Complications
Cholangitis, obstructive jaundice, gallstone-induced pancreatitis, and secondary biliary cirrhosis.
| TREATMENT | ||
Choledocholithiasis/CholangitisLaparoscopic cholecystectomy and ERCP have decreased the need for choledocholithotomy and T-tube drainage of the bile ducts. When CBD stones are suspected prior to laparoscopic cholecystectomy, preoperative ERCP with endoscopic papillotomy and stone extraction is the preferred approach. CBD stones should be suspected in gallstone pts with (1) history of jaundice or pancreatitis, (2) abnormal LFT, and (3) ultrasound evidence of a dilated CBD or stones in the duct. Cholangitis treated like acute cholecystitis; no oral intake, hydration, analgesia, and antibiotics are the mainstays; stones should be removed surgically or endoscopically. |