Choledocholithiasis

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Choledocholithiasis is the presence of gallstones in the common bile duct. This condition causes jaundice and liver cell damage, and is a medical emergency, requiring the endoscopic retrograde cholangiopancreatography (ERCP) procedure or surgical treatment. A tendency for this disease can be inherited.

There is limited information about the historical perspective of choledocholithiasis

Choledocholithiasis can be classified as Primary or Secondary. Primary Choledocholithiasis is classified based on gallstones formed directly within the biliary and obstructing the common bile duct. Primary Choledocholithiasis is composed of brownstones and is less common compared to secondary choledocholithiasis. Primary choledocholithiasis often affect the biliary tree diffusely and have both intrahepatic and extrahepatic biliary stones. Intrahepatic stones may be complicated by recurrent pyogenic cholangitis.Secondary Choledocholithiasis is classified based on gallstones formed from the gallbladder and transported to block the common bile duct. This type of Choledocholithiasis is the most common type of Choledocholithiasis. The stone composition of secondary choledocholithiasis is similar to cholelithiasis with cholesterol stone as the most common type, and the cause is identical to the causes of gallstones.

It is understood that the Bile is made in the liver and stored in the gallbladder. Concentrated bile from the gallbladder can lead to the formation of gallstone. The stone passes from the gallbladder to the cystic duct, then into the common bile duct (CBD), and block the CBD. Primary Choledocholithiasis is formed from stones within the bile duct that occur due to bile stasis in the CBD, forming an intraductal stone. The cause of bile duct stasis includes bile duct dilatation with increasing age. Less commonly, bile stasis can result from complications from Mirizzi Syndrome or hepatolithiasis (gallstone in the biliary duct of the liver). The obstructed flow of the bile duct leads to obstructive jaundice and possibly hepatitis. The stagnant Bile can lead to infection and inflammation of the bile duct, causing bactibilia and ascending cholangitis. If the blockage is at the common bile duct after the pancreatic duct, join the CBD, it can become inflamed, with autoactivation of pancreatic enzymes leading to gallstone pancreatitis

While stones can frequently pass through the common bile duct into the duodenum, some stones may be too large to pass through the CBD and will cause an obstruction. Choledocholithiasis causes include primary and secondary causes. Primary causes are rare, and they are usually brown pigment stones formed in the bile duct. Recurrent pyogenic cholangitis (RCC), also known as Oriental Cholangiohepatitis hepatolithiasis, is an intrahepatic brown pigment stone exclusive to individuals who live or lived in southeast Asia. It is caused by a bacterial in the bile duct, undernutrition, and parasitic infection (e.g., Clonorchis Sinensis, Opisthorchis viverrini) leading to chronic bacterial cholangitis with hepatolithiasis|primary hepatolithiasis. Secondary causes occur in greater than 85% of people in a developed country, and about 10% presents symptomatically after Cholecystectomy. Secondary causes are caused by stones from the gallbladder, with cholesterol stones being the most common.

Choledocholithiasis must be differentiated from other diseases that cause jaundice, right upper quadrant pain, fever, nausea and vomiting, such as Cholecystitis, Perforated peptic ulcer, Acute peptic ulcer exacerbation, Amoebic liver abscess, Acute amoebic liver colitis, Acute pancreatitis, Acute intestinal obstruction, Renal colic, Acute retrocolic appendicitis.

The incidence and prevalence of choledocholithiasis are unknown, but Choledocholithiasis has been found in 4.6% to 18.8% of patients undergoing cholecystectomy.

Common risk factors in the development of Choledocholithiasis are the same as gallstones which include being a female, age 40 or older, obesity, pregnancy, high-fat diet, rapid weight loss, and liver disease. Risk Factors can be classified as either modifiable or non-modifiable.

There is insufficient evidence to recommend routine screening for Choledocholithiasis.

The choledocholithiasis symptoms typically develop as a result of stone from the gallbladder blocking the common bile duct or from stone formation within the bile duct, usually asymptomatic. According to Wenckert et al., approximately 25–50% of patients with retained bile duct stones developed severe complications, mainly jaundice or pancreatitis.

Symptoms usually do not occur unless the stone blocks the common bile duct. Symptoms that may occur include, Abdominal pain in the right upper or middle upper abdomen that may come and go, sharp, cramping, or dull, Spread to the back or below the right shoulder blade, Get worse after eating fatty or greasy foods, Occurs within minutes of a meal along with Fever, Loss of appetite and Jaundice (yellowing of skin and whites of eyes).

Patients with choledocholithiasis usually asymptomatic. Physical examination of patients with choledocholithiasis is usually non-remarkable. The physical finding is associated with the complication of the disease.

The laboratory data may be normal in as many as a thirds of patients with choledocholithiasis, and further evaluation of the Common bile duct is recommended by imaging studies to clarify the diagnosis.

Ultrasound is helpful first in establishing a diagnosis of Choledocholithiasis and the most common screening tool used for choledocholithiasis. Findings on ultrasound suggestive of Choledocholithiasis include dilated bile duct, visualization of stone(s), and gallstones should increase suspicion.

There is no medical therapy for choledocholithiasis; the mainstay of therapy for symptomatic choledocholithiasis is surgery and reducing risk factors. Medical therapy used to treat gallstone can be recommended to choledocholithiasis secondary to gallstone.

The goal of treatment is to relieve the blockage. Surgery is the mainstay of treatment for symptomatic choledocholithiasis. The procedure is Biliary endoscopic sphincterotomy, an essential procedure of endoscopic retrograde cholangiopancreatography (ERCP). The procedure involves cutting the sphincter between the common bile duct and the pancreatic duct using a flexible catheter and wire to remove the stone.

Effective measures for the primary prevention include diet with sufficient fat and protein, maintaining a low body weight, and avoiding prolonged fasting.

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There is limited information about the historical perspective of choledocholithiasis

There is limited information about the historical perspective of choledocholithiasis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Adenike Eketunde

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Choledocholithiasis can be classified as Primary or Secondary.

Choledocholithiasis can be classified as Primary or Secondary

• Primary Choledocholithiasis is classified based on gallstones formed directly within the biliary and obstructing the common bile duct. Primary Choledocholithiasis is composed of brownstones and is less common compared to secondary choledocholithiasis. Primary choledocholithiasis often affect the biliary tree diffusely and have both intrahepatic and extrahepatic biliary stones. Intrahepatic stones may be complicated by recurrent pyogenic cholangitis.^[1]

• Secondary Choledocholithiasis is classified based on gallstones formed from the gall bladder and transported to block the common bile duct. This type of Choledocholithiasis is the most common type of Choledocholithiasis. The stone composition of secondary choledocholithiasis is similar to cholelithiasis with cholesterol stone as the most common type, and the cause is identical to the causes of gallstones. About 4.6% to 18.8% of patients undergoing cholecystectomy is found to have choledocholithiasis.^[2]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Adenike Eketunde

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It is thought that Choledocholithiasis is the result of gallstone produced either in the gall bladder or bile duct obstructing the common bile duct.

It is understood that the Bile is made in the liver and stored in the gallbladder. Concentrated bile from the gallbladder can lead to the formation of gallstone. The stone passes from the gallbladder to the cystic duct, then into the common bile duct (CBD), and block the CBD. ^[1]

Primary Choledocholithiasis is formed from stones within the bile duct that occur due to bile stasis in the CBD, forming an intraductal stone. The cause of bile duct stasis includes bile duct dilatation with increasing age. Less commonly, bile stasis can result from complications from Mirizzi Syndrome or hepatolithiasis (gallstone in the biliary duct of the liver). The obstructed flow of the bile duct leads to obstructive jaundice and possibly hepatitis. The stagnant Bile can lead to infection and inflammation of the bile duct, causing bactibilia and ascending cholangitis. If the blockage is at the common bile duct after the pancreatic duct, join the CBD, it can become inflamed, with autoactivation of pancreatic enzymes leading to gallstone pancreatitis. Choledocholithiasis can also be secondary to cholelithiasis and choledochoduodenal-fistula stricture. choledochoduodenal-fistula is an abnormal opening in choledochus and the duodenum and a rare complication of chronic duodenal ulcer with cholelithiasis. The stone formed in the gallstone and transported to the gallbladder usually pure choleterol stone, but can be pigment stones or mixed composition. The cholesterol stone is formed from supersaturation of cholesterol when there is not enough bile to saturate the choleterol in solution or impaired motility of the gallbladder. Pigment stone are formed from red blood cells breakdown.^{[2] [3] [4] [5]}

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Adenike Eketunde

Choledocholithiasis causes include primary and secondary causes.

While stones can frequently pass through the common bile duct into the duodenum, some stones may be too large to passthrough the CBD and will cause an obstruction. Choledocholithiasis causes include primary and secondary causes.

• Primary causes are rare, and they are usually brown pigment stones formed in the bile duct. Recurrent pyogenic cholangitis (RCC), also known as Oriental Cholangiohepatitis hepatolithiasis, is an intrahepatic brown pigment stone exclusive to individuals who live or lived in southeast Asia. It is caused by a bacterial in the bile duct, undernutrition, and parasitic infection (e.g., Clonorchis Sinensis, Opisthorchis viverrini) leading to chronic bacterial cholangitis with hepatolithiasis|primary hepatolithiasis.
• Secondary causes occur in greater than 85% of people in a developed country, and about 10% presents symptomatically after Cholecystectomy. Secondary causes are caused by stones from the gallbladder, with cholesterol stones being the most common.

Other causes include residual stones that develop in the ducts greater than three years after surgery.^[1]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Adenike Eketunde

Choledocholithiasis must be differentiated from other diseases that cause jaundice, right upper quadrant pain, fever, nausea and vomiting, such as Cholecystitis, Perforated peptic ulcer, Acute peptic ulcer exacerbation, Amoebic liver abscess, Acute amoebic liver colitis, Acute pancreatitis, Acute intestinal obstruction, Renal colic, Acute retrocolic appendicitis.

Choledocholithiasis must be differentiated from

• Cholecystitis
• Perforated peptic ulcer
• Acute peptic ulcer exacerbation
• Amoebic liver abscess
• Acute amoebic liver colitis
• Acute pancreatitis
• Acute intestinal obstruction
• Renal colic
• Acute retrocolic appendicitis
• Bile duct cancer
• Klatskin tumor
• Bile duct stricture
• Choledochal cyst
• Peptic ulcer disease
• Sphincter of Oddi dysfunction
• Functional gallbladder disorder. ^[1]

Abbreviations: RUQ= Right upper quadrant of the abdomen, LUQ= Left upper quadrant, LLQ= Left lower quadrant, RLQ= Right lower quadrant, LFT= Liver function test, SIRS= Systemic inflammatory response syndrome, ERCP= Endoscopic retrograde cholangiopancreatography, IV= Intravenous, N= Normal, AMA= Anti mitochondrial antibodies, LDH= Lactate dehydrogenase, GI= Gastrointestinal, CXR= Chest X ray, IgA= Immunoglobulin A, IgG= Immunoglobulin G, IgM= Immunoglobulin M, CT= Computed tomography, PMN= Polymorphonuclear cells, ESR= Erythrocyte sedimentation rate, CRP= C-reactive protein, TS= Transferrin saturation, SF= Serum Ferritin, SMA= Superior mesenteric artery, SMV= Superior mesenteric vein, ECG= Electrocardiogram, US = Ultrasound

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Adenike Eketunde

The incidence and prevalence of choledocholithiasis are unknown, but Choledocholithiasis has been found in 4.6% to 18.8% of patients undergoing cholecystectomy

• The incidence and prevalence of choledocholithiasis are unknown, but Choledocholithiasis has been found in 4.6% to 18.8% of patients undergoing cholecystectomy.^[1]
• The incidence of choledocholithiasis increases with age.
• There is no racial predilection to choledocholithiasis.
• Females are more commonly affected by choledocholithiasis than males. The ratio is unknown.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Adenike Eketunde

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Common risk factors in the development of Choledocholithiasis are the same as gallstone, which includes being a female, age 40 or older, obesity, pregnancy, high-fat diet, rapid weight loss, and liver disease.

Common risk factors in the development of Choledocholithiasis are the same as gallstones which include being a female, age 40 or older, obesity, pregnancy, high-fat diet, rapid weight loss, and liver disease. Risk Factors can be classified as either modifiable or non-modifiable

• Modifiable risk factors
  • Cholecystectomy
  • obesity
  • low-fiber, high-calorie, high-fat diet
  • pregnancy
  • prolonged fasting
  • rapid weight loss
  • lack of physical activity

• Non-modifiable risk factors
  • Age: older adults typically have a higher risk for gallstones
  • Gender: women are more likely to have gallstones
  • Ethnicity: Asians, American Indians, and Mexican Americans are at higher risk for gallstones
  • Family history: genetics may play a role. ^[1].^[2]

Choledocholithiasis can also occur in people who have had their gallbladder removed

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Adenike Eketunde

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There is insufficient evidence to recommend routine screening for Choledocholithiasis

There is insufficient evidence to recommend routine screening for Choledocholithiasis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Adenike Eketunde

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The choledocholithiasis symptoms typically develop as a result of stone from the gallbladder blocking the common bile duct or from stone formation within the bile duct, usually asymptomatic. According to Wenckert et al., approximately 25–50% of patients with retained bile duct stones developed severe complications, mainly jaundice or pancreatitis. ^[1]

• Biliary cirrhosis
• Cholangitis
• Pancreatitis
• Acute cholelithiasis
• Gallstones ileus

Prognosis is generally not associated with increase mortality. However, the prognosis from complications such as pancreatitis, cholangitis, secondary biliary cirrhosis can be fatal. Blockage and infection caused by stones in the biliary tract can be life threatening. However, with prompt diagnosis and treatment, the outcome is usually very good.

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