Snapshot A 45-year-old obese woman presents to the emergency room with right upper quadrant pain for the past 5 hours. She reports that for the past few years, she has had increasing transient right upper quadrant pain especially after meals. Physical exam reveals tenderness to palpation in the right upper quadrant and negative Murphy sign. Laboratory results show increased alkaline phosphatase and total bilirubin. A right upper quadrant ultrasound shows a dilated common bile duct, suggestive of choledocholithiasis. She is admitted and scheduled for an MRCP. Introduction Clinical definition gallstones in common bile duct Associated conditions acute ascending cholangitis acute pancreatitis Epidemiology Demographics female > male ~10-20% of patients who undergo cholecystectomy Risk factors gallstones female gender age obesity ETIOLOGY Pathogenesis gallstones in common bile duct cause ↑ obstruction, leading to jaundice, acute pancreatitis, and acute cholangitis Presentation Symptoms nausea vomiting fever colicky right upper quadrant pain postprandial Physical exam palpation right upper quadrant tenderness imaging Right upper quadrant ultrasound best initial imaging findings gallstones with possible sludge biliary dilatation Magnetic resonance cholangiopancreatography (MRCP) indications high sensitivity for common bile duct gallstones may guide endoscopic vs surgical interventions preferred over endoscopic ultrasound (EUS) patients with intermediate risk of choledocholithiasis findings dilated intrahepatic biliary ducts Endoscopic ultrasound (EUS) indication if there is still suspicion of choledocholithiasis even after cholecystectomy with abnormal lab findings patients with intermediate risk of choledocholithiasis Endoscopic retrograde cholangiopancreatography (ERCP) indication patients with high risk of choledocholithiasis both diagnostic and therapeutic (see below) Studies Diagnostic approach laboratory evaluation and right upper quadrant ultrasound are used for risk stratification and will guide further imaging (MRCP vs EUS vs ERCP) risk stratification of choledocholithiasis (American Society of Gastrointestinal Endoscopy) high risk → ERCP common bile duct stone on ultrasound clinical ascending cholangitis ↑ serum bilirubin > 4 mg/dL intermediate risk → MRCP or EUS dilated common bile duct abnormal liver function tests age > 55 years of age gallstone pancreatitis low risk → eventual cholecystectomy symptoms suggestive of choledocholithiasis no other definitive findings Diagnostic testing studies ↑ or normal white blood cell count ↑ alkaline phosphatase ↑ GGT ↑ total and direct bilirubin mild ↑ liver enzymes Differential Primary sclerosing cholangitis distinguishing factor patients often have concomitant autoimmune disease “onion skin” bile duct fibrosis associated with ulcerative colitis and cholangiocarcinoma Choledochal cyst distinguishing factor choledochal cyst is a congenital defect of bile duct that results in intra and extra hepatic dilatation of the bile ducts may also present with abdominal pain, jaundice, and cholangitis however, often presents in infancy DIAGNOSIS Diagnostic criteria hallmark is ↑ alkaline phosphatase and ↑ total and direct bilirubin imaging suggestive of common bile duct stones dilated common bile duct Treatment Management approach removal of common bile duct gallstone First-line endoscopic retrograde cholangiopancreatography (ERCP) often with sphincterotomy indications choledocholithiasis with acute ascending cholangitis not responsive to medical treatment gallstone pancreatitis diagnostic and therapeutic adverse effects post-ERCP pancreatitis cholangitis laparoscopic cholecystectomy indications to prevent recurrence cholelithiasis often within 72 hours of ERCP Other treatments ursodeoxycholic acid indications prophylaxis after gallstones are cleared from common bile duct Complications Gallstone ileus Gallstone pancreatitis Hepatic abscess