Choledocholithiasis Clinical Overview
I. The "On-Call" Snapshot
Clinical Significance in Malaysia: This is a bread-and-butter diagnosis for any surgical or medical posting. It's a very common cause of obstructive jaundice and a key differential for the septic patient with abdominal pain.
High-Yield Definition: Choledocholithiasis is the presence of one or more gallstones in the common bile duct (CBD).
Clinical One-Liner: Basically, a stone has escaped the gallbladder and is now blocking the main pipe that drains bile from the liver into your gut.
II. Etiology & Risk Factors
Etiology:
Secondary (Most Common, >95%): Stones form in the gallbladder (cholelithiasis) and migrate into the CBD. These are typically cholesterol stones.
Primary (Less Common): Stones form de novo within the bile ducts. These are usually brown pigment stones, often associated with biliary stasis and infection (e.g., post-surgical strictures, or in cases of Recurrent Pyogenic Cholangitis which we see in Southeast Asia).
Risk Factors: Essentially the same as for cholelithiasis. Remember the "4 Fs", but be more comprehensive.
Non-Modifiable: Female gender, increasing age (>40), ethnicity (higher in certain Asian populations), family history.
Modifiable: Obesity, metabolic syndrome, rapid weight loss (e.g., post-bariatric surgery), prolonged fasting/TPN, high-fat diet.
III. Quick Pathophysiology
This is simple, don't overthink it.
Obstruction: A stone lodges in the CBD.
Increased Pressure: Bile backs up, causing biliary ductal pressure to rise. This stretches the biliary tree, causing the classic RUQ/epigastric pain (biliary colic).
Jaundice & Cholestasis: Conjugated bilirubin can't be excreted, so it spills into the bloodstream, causing jaundice, dark urine, and pale stools. This leads to the characteristic rise in Alkaline Phosphatase (ALP) and Gamma-Glutamyl Transferase (GGT).
Infection (Cholangitis): The stagnant bile is an excellent culture medium for bacteria ascending from the duodenum (commonly E. coli, Klebsiella). This leads to acute cholangitis, which is a medical emergency.
IV. Clinical Assessment
Red Flags & Immediate Actions: If you see these, you call your senior immediately. This is not for you to manage alone.
Fever (especially with rigors) + RUQ Pain + Jaundice (Charcot's Triad): You are dealing with Acute Cholangitis until proven otherwise.
Action: Alert senior, secure TWO large-bore IV cannulas, start IV fluids, take blood cultures, and start broad-spectrum IV antibiotics as per hospital protocol (e.g., IV Piperacillin/Tazobactam).
Hypotension or Altered Mental Status (Reynolds' Pentad): This is septic shock from obstructive cholangitis.
Action: Call for a medical emergency team (MET) call if needed. This patient needs urgent resuscitation and is likely heading for emergent biliary decompression.
History:
Common (>50%): Severe, constant epigastric or RUQ pain, jaundice.
Less Common (10-50%): Nausea, vomiting, dark "teh-o" coloured urine, pale/acholic stools, pruritus (itching due to bile salt deposition).
Pertinent Negatives: Ask about recent intake of a fatty meal. Ask about weight loss or loss of appetite to rule out malignancy.
Physical Examination:
General: Check for jaundice (sclera, under the tongue), signs of sepsis (tachycardia, hypotension).
Abdomen: Tenderness in the RUQ or epigastrium. Murphy's sign is usually negative unless there's concurrent acute cholecystitis. A palpable gallbladder (Courvoisier's sign) is rare and suggests a malignant obstruction, not a stone.
Clinical Pearl: Painful jaundice points towards a stone. Painless jaundice is more sinister and points towards a tumour. Remember this when you clerk patients.
V. Diagnostic Workflow
Differential Diagnosis:
Acute Cholecystitis:
Points For: RUQ pain, fever, leukocytosis.
Points Against: Significant jaundice is uncommon.
How to Differentiate: Ultrasound shows gallbladder wall thickening/pericholecystic fluid, and Murphy's sign is positive. LFTs are less deranged.
Acute Pancreatitis:
Points For: Severe epigastric pain radiating to the back.
Points Against: Jaundice is only present if a stone is impacted at the ampulla.
How to Differentiate: Serum amylase/lipase is >3x the upper limit of normal.
Acute Hepatitis (Viral/Drug-induced):
Points For: Jaundice, RUQ discomfort, nausea.
Points Against: Pain is usually less severe. May have a prodrome of fever and myalgia.
How to Differentiate: LFTs show a hepatocellular pattern (ALT/AST in the thousands) rather than a cholestatic one (markedly raised ALP/GGT).
Investigations Plan:
Bedside / Initial (First 15 Mins):
Vital Signs: Crucial for detecting sepsis.
ECG: To rule out an inferior MI presenting as epigastric pain.
Urine FEME: Check for bilirubinuria (positive) and urobilinogen (absent/reduced).
First-Line Labs & Imaging:
Bloods:
Liver Function Test (LFT): Expect a cholestatic/obstructive picture: ↑ ALP, ↑ GGT, ↑ Total and Direct Bilirubin. ALT/AST may be mildly elevated.
Full Blood Count (FBC): Leukocytosis suggests cholangitis.
Renal Profile (RP): To check for acute kidney injury in sepsis.
Coagulation Profile: Essential before any endoscopic procedure.
Blood C&S: If the patient is febrile.
Imaging:
Transabdominal Ultrasound (USS): This is your first-line imaging. It might not see the stone itself, but it will show you indirect evidence: a dilated CBD (>6-7 mm). This finding is the key trigger for your next step. It will also show if there are stones in the gallbladder.
Confirmatory / Gold Standard:
Magnetic Resonance Cholangiopancreatography (MRCP): This is the non-invasive gold standard for diagnosing CBD stones. It's essentially an MRI of the biliary tree. It will confirm the presence, size, and location of the stone(s).
Endoscopic Retrograde Cholangiopancreatography (ERCP): This is the gold standard for treatment. It is invasive, so we only do it when we are highly suspicious and ready to intervene. Diagnose with MRCP, treat with ERCP.
VI. Staging & Severity Assessment
For patients with cholangitis, we use the Tokyo Guidelines 18 (TG18) to classify severity. This determines the urgency of biliary drainage.
Grade III (Severe): Evidence of organ dysfunction (e.g., hypotension needing vasopressors, altered consciousness, severe renal/hepatic dysfunction, coagulopathy). Requires emergent drainage (<12 hours).
Grade II (Moderate): Associated with two or more conditions like high fever (>39°C), high WCC, elderly age (>75), or hyperbilirubinemia. Requires early drainage (<48-72 hours).
Grade I (Mild): Meets diagnostic criteria for cholangitis but not moderate or severe criteria. Responds to initial medical treatment. Drainage can be done electively.
VII. Management Plan
Immediate Stabilisation (The A&E Plan):
A, B, C: Ensure airway is patent, give oxygen if hypoxic, monitor circulation.
D: IV access (x2 large bore), start fluid resuscitation (e.g., Normal Saline 0.9% bolus) if hypotensive.
E: Keep patient Nil Per Os (NPO).
Meds:
IV Analgesia: e.g., IV Pethidine 50mg or IV Tramadol 50mg.
IV Antibiotics: If any sign of infection, start broad-spectrum coverage immediately after taking blood cultures. A common choice in our setting is IV Piperacillin-Tazobactam 4.5g TDS.
IV anti-emetics: e.g., IV Metoclopramide 10mg.
Definitive Treatment (The Ward Round Plan):
The goal is to remove the stone and decompress the biliary system.
First-Line: ERCP with sphincterotomy and stone extraction. A scope is passed into the duodenum, the biliary sphincter is cut (sphincterotomy), and a balloon or basket is used to pull the stone out.
If ERCP fails or stones are too large: A temporary plastic stent may be placed to ensure bile drainage, with a plan for a repeat procedure or alternative treatment.
Surgical Options (Rarely first-line now): Laparoscopic or open CBD exploration. Reserved for cases where ERCP fails or is not available.
Long-Term & Discharge Plan:
Cholecystectomy: Once the patient has recovered from the ERCP and the acute illness, they MUST be counselled for and scheduled for a cholecystectomy (usually laparoscopic). Removing the gallbladder prevents recurrence, which is very high otherwise. This is a critical part of the management.
VIII. Complications
From the Disease:
Immediate: Acute Cholangitis, Sepsis, Acute Pancreatitis, Hepatic abscess.
From Management (ERCP):
Short-Term: Post-ERCP Pancreatitis (PEP) (most common, ~5%), bleeding from the sphincterotomy site, perforation of the duodenum or bile duct, cholangitis.
IX. Prognosis
Excellent if diagnosed and treated promptly.
Mortality is directly related to the complications, especially severe cholangitis with septic shock, where it can be significant (>10%).
Top 3 prognostic factors are the presence of severe cholangitis (organ failure), patient's age, and underlying comorbidities.
X. How to Present to Your Senior
Use a clear, structured approach.
"Dr, for review please. This is Puan Aminah in Bed 10, a 65-year-old lady with T2DM, who presented with 1 day of severe RUQ pain and jaundice.
On examination, she is febrile at 38.5°C, tachycardic at 110, but her blood pressure is stable. She is alert and has marked RUQ tenderness.
Her initial bloods show a cholestatic LFT with a total bilirubin of 150 and ALP of 400, with a white cell count of 15.
My main differential is choledocholithiasis complicated by acute cholangitis.
I have already sent off blood cultures, started IV Tazocin, and kept her nil by mouth. The surgical team has been informed. I would like to request an urgent ultrasound to look for CBD dilatation and then discuss with gastroenterology for an ERCP."
XI. Summary & Further Reading
Top 3 Takeaways:
Suspect choledocholithiasis in any patient with RUQ pain and an obstructive LFT pattern.
The presence of fever (Charcot's Triad) means Acute Cholangitis. Treat it as sepsis and act fast.
The management pathway is: Resuscitate -> Investigate (USS -> MRCP) -> Treat (ERCP) -> Prevent Recurrence (Cholecystectomy).
Key Resources:
UpToDate: Search for "Choledocholithiasis: Clinical manifestations, diagnosis, and management".
Amboss: Search "Choledocholithiasis" and "Acute Cholangitis".
Tokyo Guidelines (TG18): This is the international standard for managing acute cholangitis and cholecystitis. [Link to a key summary or publication of TG18, e.g., on PubMed].
Now go and clerk your patients. If you're unsure, ask. It's better to ask a stupid question than to miss a septic patient.
