|Classification and external resources|
Common bile duct stone impacted at ampulla of Vater seen at time of ERCP
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.
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 may cause an obstruction. One risk factor for this is duodenal diverticulum.
This obstruction may leads to jaundice, elevation in alkaline phosphatase, increase in conjugated bilirubin in the blood and increase in cholesterol in the blood. It can also cause acute pancreatitis and ascending cholangitis.
Choledocholithiasis (stones in common bile duct) is one of the complications of cholelithiasis (gallstones), so the initial step is to confirm the diagnosis of cholelithiasis. Typically patients with cholelithiasis present with pain in the right upper quadrant of the abdomen with the associated symptoms of nausea and vomiting, especially after a fatty meal. The physician can confirm the diagnosis of cholelithiasis with an abdominal ultrasound that shows the ultrasonic shadows of the stones in the gallbladder.
The diagnosis of choledocholithiasis is suggested when the liver function blood test shows an elevation in bilirubin. The diagnosis is confirmed either with an MRCP, ERCP, or an intraoperative cholangiogram. If the patient must have the gallbladder removed for gallstones, the surgeon may choose proceed with the surgery, and obtain a cholangiogram during the surgery. If the cholangiogram shows stone in the bile duct, the surgeon may attempt to treat the problem by flushing the stone into the intestine or retrieve the stone back through the cystic duct.
On a different pathway, the physician may choose to proceed with ERCP before surgery. The benefit of ERCP is that it can be utilized not just to diagnose, but also to treat the problem. During ERCP the endoscopist may surgically widen the opening into the bile duct and remove the stone through that opening. ERCP, however, is an invasive procedure and has its own potential complication. Thus, if the suspicion is low, the physician may choose to confirm the diagnosis with MRCP, a non-invasive imaging, before proceeding with ERCP or surgery.
Treatment involves removing the stone using ERCP. Typically, the gallbladder is then removed, an operation called cholecystectomy, to prevent a future occurrence of common bile duct obstruction.