Competing interests: Alan Barkun has received consultancy fees from Takeda Canada and Olympus, and speaker fees from AstraZeneca Canada, Takeda Canada and Sanofi-Aventis, conducted research sponsored by grants from Cook and Boston Scientific, and has received payment from AstraZeneca Canada for the development of educational presentations. No competing interests declared by Majid Almadi or Jeffrey Barkun.
When surgery is not an option and stones cannot be removed from the common bile duct by endoscopic methods alone, or when ERCP cannulation fails repeatedly, percutaneous transhepatic cholangiography can be used to facilitate access to the biliary tree through a rendezvous procedure. Targeted percutaneous lithotripsy can also be helpful, but oral dissolution therapy is only of historical interest because of its poor efficacy and safety.
Stratification of the probability of common bile duct stones was used in a prospective study involving 440 patients undergoing laparoscopic cholecystectomy. It was used to select the approach to imaging and management: ERCP if the probability is extremely high, magnetic resonance cholangiopancreatography if it is high, laparoscopic cholecystectomy with intraoperative cholangiography if it is intermediate, and laparoscopic cholecystectomy without intraoperative cholangiography if the probability is low. 6 The use of this stratification system resulted in the discriminatory detection of stones in 92.6%, 32.4%, 3.8% and 0.9% of the patients respectively. 6 The proportion of patients with retained stones after two years was 1.4%.
We performed a literature search of the Embase (1980 to October 2011), MEDLINE (1950 to October 2011) and Cochrane Library databases. We used a combination of MeSH subject headings and text words, including “choledocholithiasis,” “cholelithiasis,” “common bile duct stone,” “intraoperative cholangiography,” “operative cholangiography,” “perioperative cholangiogram,” “rendezvous,”and “meta-analysis.” Reference lists from selected articles were reviewed manually to identify additional articles. All data were abstracted and recorded in dedicated forms and reviewed by two of us (M.A.A., A.N.B.). Resolution of any discrepancies in data abstraction was achieved through consensus involving a third person (J.S.B.). We included trials with the highest level of evidence; observational studies were included if no controlled trials were available. (For details of the search strategy, see Appendix 1, available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.110896/-/DC1).
The investigation of possible “silent” stones remains controversial, because such stones may pass spontaneously without causing symptoms.
Imaging modalities for detecting stones in the common bile duct 4
On the basis of findings in the current literature, we propose a simplified algorithm for the management of patients with suspected common bile duct stones before laparoscopic cholecystectomy ( Figure 1 ). The algorithm is similar to one issued by the American Society for Gastrointestinal Endoscopy. 17 Several organizations have published guidelines on selected aspects of the management of common bile duct stones ( Table 3 ; 1 , 17 , 19 – 27 see also Appendix 4, available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.110896/-/DC1).
Pre-versus intraoperative ERCP
Most of the studies of treatment strategies that we identified included patients with symptomatic common bile duct stones. The common practice is to remove common bile duct stones in patients presenting with symptoms. Indeed, most patients who are symptomatic will have recurrent symptoms if their condition is left untreated. 42
The management of gallstone pancreatitis, discussed in the following section, is one area that has changed substantially over the last few years.
- Digestive system
- Kidney cyst with gallstones – CT scan
- Bile pathway
Li S, Zenlea T. Choledocholithiasis. In: Ferri FF, ed. Ferri’s Clinical Advisor 2022. Philadelphia, PA: Elsevier; 2022:368-369.
Call your provider if:
Often, there are no symptoms unless the stone blocks the common bile duct. Symptoms may include:
Blockage and infection caused by stones in the biliary tract can be life threatening. Most of the time, the outcome is good if the problem is detected and treated early.
Tests that show the location of stones in the bile duct include the following:
Fogel EL, Sherman S. Diseases of the gallbladder and bile ducts. In: Goldman L, Schafer AI, eds. Goldman-Cecil Medicine. 26th ed. Philadelphia, PA: Elsevier; 2020:chap 146.
Choledocholithiasis is the presence of at least one gallstone in the common bile duct. The stone may be made up of bile pigments or calcium and cholesterol salts.
Treatment may involve: