Review Question - QID 107756

This patient presenting with recurrent bouts of abdominal pain is concerning for biliary colic. The progression of symptoms to include pruritus, acholic stools, jaundice, and an ERCP showing a common bile duct stone would most likely manifest with a cholestatic pattern such as elevated alkaline phosphatase, total bilirubin, and gamma-glutamyl transferase.

Choledocholitiasis, or obstruction of the biliary tree by a gallstone, is a common complication of cholelithiasis. Incidence of choledocolithiasis occurs in about 10-15% of individuals with gallbladder stones. Risk factors are similar to those of gallbladder stones, mainly the 5 F's of being female, forty (middle age), fat (obesity), fertile (estrogen increases risk), and presenting with flatulence (acholic stools and hyperbilirubinurea). As mentioned above, laboratory studies will demonstrate a cholestatic pattern, and definitive diagnosis is readily made with ERCP or magnetic resonance cholangiopancreatography (MRCP).

Abraham et al. discuss the management of gallstones. They comment that common duct stones can vary in presentation from being asymptomatic, to leading to complications such as acute cholangitis and gallstone pancreatitis. Ascending cholangitis should be suspected in individuals presenting with Charcot's triad of fever, jaundice, and abdominal pain. They recommend antibiosis and definitive therapy with ERCP and sphincterotomy.

Maple et al. discuss the ASGE Standards of Practice Committee on the role of endoscopy for suspected choledocholithiasis. The committee recommends initial evaluation with a right upper quadrant ultrasound, which may demonstrate a dilated common bile duct (> 6mm or >4mm + 1mm for every decade older than 40 years) as well as sonographic evidence of gallbladder stones with multiple <5mm stones posing a 4-fold higher risk of migration into the duct. Another highly suggestive finding is a total bilirubin of > 4 mg/dL.

Figure A shows an ERCP with a two filling defects in the common bile duct; of note, the pancreatic duct is widely patent.

Incorrect Answers:
Answer 1: Liver specific enzymes can be elevated in choledocholithiasis but alkaline phosphatase and gamma-glutamyl transferase are more markedly elevated in a cholestatic pattern of injury.
Answer 2: Choledocholithiasis would produce a conjugated or direct hyperbilirubinemia. Causes of elevated indirect bilirubin include Gilbert's syndrome and Crigler Najjar syndrome.
Answer 4: Elevated Anti-mitochondrial antibodies are often found in individuals with primary biliary cirrhosis.
Answer 5: Choledocholithiasis can lead to pancreatitis if the stone becomes impacted distal to the commissure of the common bile duct and the pancreatic duct. This patient's ERCP shows a widely patent pancreatic duct.