Updated: 6/10/2019

Choledocholithiasis

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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
  • Epidemiology
    • demographics
      • female > male
      • ~10-20% of patients who undergo cholecystectomy
    • risk factors
      • gallstones
      • female gender
      • age
      • obesity
  • Pathogenesis
    • gallstones in common bile duct cause ↑ obstruction, leading to jaundice, acute pancreatitis, and acute cholangitis
  • Associated conditions
    • acute ascending cholangitis
    • acute pancreatitis
Presentation
  • Symptoms
    • nausea
    • vomiting
    • fever
    • colicky right upper quadrant pain
      • postprandial
  • Physical exam
    • palpation
      • right upper quadrant tenderness
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
    • 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
      • ↑ or normal white blood cell count
      • ↑ alkaline phosphatase
      • ↑ GGT
      • ↑ total and direct bilirubin
      • mild ↑ liver enzymes
  • Diagnostic criteria
    • hallmark is ↑ alkaline phosphatase and ↑ total and direct bilirubin
    • imaging suggestive of common bile duct stones
      • dilated common bile duct
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
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
 

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Questions (2)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.GI.4694) A 32-year-old female presents to the emergency department with abdominal pain and new onset itching all over. The patient has experienced recurrent abdominal discomfort, but was unable to get care due to lack of insurance. More recently, she has noticed the onset of pale-tan colored stools, and dark yellow urine. Vitals are T 101.0 F HR 93 bmp BP 126/93 mmHg RR 15 rpm SpO2 98% On physical exam, sclera are notably icteric. Abdominal exam demonstrates right upper quadrant and epigastric tenderness without guarding or rebound. Endoscopic retrograde cholangiopancreatography (ERCP) is shown in Figure A. Which of the following lab findings are most likely present? Review Topic

QID: 107756
FIGURES:
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Elevated AST and ALT

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Elevated indirect billirubin

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Elevated alkaline phosphatase

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Elevated Anti-mitochondrial antibodies

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Elevated Lipase

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M2

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