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)

(M2.GI.16.4694) 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? Tested Concept

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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5

Elevated Lipase

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M 6 B

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