Choledocholithiasis
Definition
Choledocholithiasis is the presence of one or more gallstones within the common bile duct (CBD). These stones can either form primarily within the duct or, more commonly, migrate from the gallbladder (1).1 This condition is a frequent cause of biliary obstruction, which can lead to significant complications such as cholangitis and pancreatitis if not diagnosed and managed promptly.2
Epidemiology
Gallstone disease is a significant health issue globally, and while specific, comprehensive prevalence data for choledocholithiasis in Malaysia is not readily available from recent national health surveys, it is a common reason for hospital admission. It is estimated that 10-20% of patients with cholelithiasis (gallstones in the gallbladder) will develop choledocholithiasis (2).3 The prevalence increases with age. While gallstone disease, in general, is more common in females, some data suggests that choledocholithiasis risk factors include older age and male sex, particularly for developing complications (3).
Pathophysiology
The pathophysiology of choledocholithiasis is twofold.
Secondary Stones (Most Common): The vast majority of CBD stones originate in the gallbladder. Cholesterol or pigment stones form in the gallbladder due to bile supersaturation, stasis, and crystal nucleation.4 These stones then pass through the cystic duct and into the common bile duct. If a stone is too large to pass through the ampulla of Vater into the duodenum, it becomes impacted, causing obstruction (4).5
Primary Stones (Less Common): These stones, typically brown pigment stones, form de novo within the bile ducts.6 This process is usually associated with bile stasis (e.g., due to a stricture, choledochal cyst, or previous surgery) and biliary tract infections. Bacterial enzymes, such as β-glucuronidase, deconjugate bilirubin, leading to the precipitation of calcium bilirubinate and stone formation (5).7
The obstruction of the CBD impedes bile flow from the liver to the duodenum.8 This leads to increased intraductal pressure, cholestasis, and a rise in conjugated bilirubin in the blood, resulting in clinical jaundice. Stagnant bile is also prone to infection, which can ascend the biliary tree, causing cholangitis.9
Clinical Presentation
Patients often present with symptoms of biliary obstruction or its complications.10 The classic presentation involves a history of biliary colic that becomes more persistent.
Diagnostic Clues: The combination of right upper quadrant (RUQ) pain, jaundice, and fever (Charcot's triad) is highly suggestive of acute cholangitis, a complication of choledocholithiasis (6).11
Common Symptoms (>50%):
Right Upper Quadrant (RUQ) or Epigastric Pain: Often described as severe, constant, and lasting longer than typical biliary colic (>6 hours) (1).
Jaundice: Yellowing of the skin and sclera.12
Dark, "tea-coloured" urine.13
Pale, "clay-coloured" stools.14
Nausea and Vomiting (4).15
Less Common Symptoms (10-50%):
Pruritus (itching) due to cholestasis.16
Low-grade fever and chills (1).17
⚠️ Red Flag Signs & Symptoms:
High-grade fever with rigors.18
Hypotension.
Altered mental status (confusion, lethargy). These three signs, in addition to RUQ pain and jaundice, constitute Reynold's Pentad, indicating severe, life-threatening ascending cholangitis with sepsis (6).19
Severe, radiating back pain, which may suggest concurrent gallstone pancreatitis.
Complications
If left untreated, choledocholithiasis can lead to severe and life-threatening complications.20
Biliary System:
Acute Cholangitis: Bacterial infection of the biliary tree due to obstruction.21 This can rapidly progress to sepsis.
Biliary Stricture: Chronic inflammation can lead to fibrosis and narrowing of the bile duct.22
Pancreatic:
Acute Pancreatitis: Obstruction at the ampulla of Vater can block the pancreatic duct, causing premature activation of pancreatic enzymes and autodigestion of the pancreas.23
Hepatic:
Secondary Biliary Cirrhosis: Prolonged obstruction and chronic inflammation can lead to irreversible liver damage and cirrhosis.24
Liver Abscess: Severe cholangitis can result in the formation of pus-filled collections in the liver.
Other:
Gallstone Ileus: A rare complication where a large stone erodes through the bile duct wall into the intestine, causing a bowel obstruction (7).
Prognosis
With timely diagnosis and endoscopic or surgical intervention, the prognosis for choledocholithiasis is excellent. The success rate for stone removal via Endoscopic Retrograde Cholangiopancreatography (ERCP) is over 90% (8). However, the prognosis worsens significantly if complications like severe cholangitis or pancreatitis develop. The mortality rate for acute cholangitis can be as high as 10% (6). Recurrence of CBD stones can occur in 5-25% of patients within several years, especially if the gallbladder is left in situ or if there are primary ductal issues (9).25
Differential Diagnosis
Acute Cholecystitis: This is a key differential due to the shared feature of RUQ pain.26 However, significant jaundice is uncommon in uncomplicated cholecystitis, as the obstruction is typically confined to the cystic duct, not the CBD. The liver function test will show a predominantly cholestatic picture (raised ALP and GGT) in choledocholithiasis, which is less pronounced in cholecystitis (1).
Malignancy (Pancreatic Head or Cholangiocarcinoma): Consider this, especially in older patients presenting with painless, progressive jaundice and significant weight loss. Courvoisier's law (a palpable, non-tender gallbladder in a jaundiced patient) suggests a malignant obstruction rather than a stone.27 An abdominal ultrasound followed by CT imaging is crucial to distinguish this (10).
Viral Hepatitis: This can present with jaundice and malaise.28 However, it is typically associated with a profound elevation in transaminases (ALT/AST) that is disproportionately higher than the alkaline phosphatase (ALP) level. A history of risk factors and viral serology will help differentiate this from an obstructive cause (10).
Primary Biliary Cholangitis / Primary Sclerosing Cholangitis: These are chronic autoimmune conditions causing cholestasis.29 They usually have an insidious onset with fatigue and pruritus, and diagnosis is supported by specific autoantibodies (e.g., AMA) and characteristic findings on MRCP, rather than an obstructing stone (10).
Investigations
Immediate & Bedside Tests
Vital Signs Monitoring: Essential to detect fever, tachycardia, or hypotension (the action), which are signs of sepsis secondary to cholangitis (the rationale).
Abdominal Ultrasound: This is the most important initial imaging test. It is non-invasive and excellent for detecting gallstones in the gallbladder and measuring the diameter of the common bile duct (the action). A CBD diameter >6 mm is suggestive of obstruction, though a normal-calibre duct does not rule out a stone (1).
Diagnostic Workup
First-Line Investigations:
Liver Function Test (LFT): This is critical to confirm a cholestatic pattern of injury. Expect a markedly elevated Alkaline Phosphatase (ALP) and Gamma-Glutamyl Transferase (GGT) with a raised conjugated bilirubin (the rationale), which strongly supports the diagnosis of biliary obstruction (the action) (1).
Full Blood Count (FBC): This is performed to identify leukocytosis (the rationale), which is a key indicator of infection (cholangitis) and helps in assessing severity (the action).30
Amylase/Lipase: An elevated level is essential for diagnosing concurrent gallstone pancreatitis (the action), which occurs when the stone obstructs the pancreatic duct orifice (the rationale).
Coagulation Profile (PT/INR): Cholestasis can impair the absorption of vitamin K, a fat-soluble vitamin, leading to a coagulopathy (the rationale), which must be identified and corrected before any invasive procedure like ERCP (the action).31
Blood Cultures: These should be drawn in any febrile patient to identify the causative organism in cholangitis (the rationale), allowing for targeted antibiotic therapy (the action).
Gold Standard (Diagnostic & Therapeutic):
Magnetic Resonance Cholangiopancreatography (MRCP): This is the non-invasive gold standard for diagnosis. It uses MRI to visualize the biliary and pancreatic ducts with high sensitivity and specificity for detecting CBD stones (the rationale), allowing for definitive planning before therapeutic intervention (the action) (2).32
Endoscopic Retrograde Cholangiopancreatography (ERCP): While MRCP is diagnostic, ERCP is the definitive therapeutic procedure. It allows for direct visualization of the ampulla, injection of contrast to confirm the stone, and immediate intervention through sphincterotomy and stone extraction (the rationale), thereby relieving the obstruction in a single session (the action) (8).33
Monitoring & Staging
Serial LFTs: These are used to monitor the resolution of cholestasis after intervention (the action), as falling bilirubin and ALP levels indicate successful drainage (the rationale).
Repeat FBC and C-Reactive Protein (CRP): These inflammatory markers are monitored to track the response to antibiotic therapy in cholangitis (the action), guiding the duration of treatment (the rationale).34
Management
(Note: While there is no specific national CPG for choledocholithiasis in Malaysia, management should follow established international guidelines which emphasize timely biliary decompression and source control.)
Management Principles
The management of choledocholithiasis focuses on three core principles: hemodynamic stabilization in case of sepsis, urgent removal of the biliary obstruction, and definitive treatment of the source of the stones (usually cholecystectomy).
Acute Stabilisation (The First Hour)
For a patient presenting with acute cholangitis and sepsis:
Airway/Breathing: Administer high-flow oxygen via a non-rebreather mask to maintain SpO2 >94% (the action), which is crucial to prevent tissue hypoxia driven by septic shock (the rationale).
Circulation: Secure two large-bore IV cannulas and administer a stat fluid bolus of IV Normal Saline 20-30mL/kg over the first hour (the action) to correct hypotension and restore end-organ perfusion (the rationale).
Disability/Exposure: Check blood glucose to rule out hypoglycemia and obtain blood cultures before starting antibiotics. Administer broad-spectrum intravenous antibiotics immediately. A common regimen based on the National Antibiotic Guidelines would be IV Ampicillin/Sulbactam 1.5-3g Q6-8H or IV Ceftriaxone 2g OD plus IV Metronidazole 500mg TDS if anaerobic coverage is desired (the action), to cover common biliary pathogens like E. coli, Klebsiella, and Enterococcus (the rationale) (11).
Definitive Therapy
First-Line Treatment:
ERCP with Endoscopic Sphincterotomy and Stone Extraction: This is the treatment of choice. After stabilizing the patient, urgent ERCP (within 24 hours for severe cholangitis) should be performed to cut the sphincter of Oddi and remove the stone using a basket or balloon (the action), which directly relieves the obstruction and drains the infected bile (the rationale) (8).
Second-Line/Escalation:
Laparoscopic/Open Common Bile Duct Exploration: This surgical option is considered if ERCP fails, if expertise is unavailable, or if there is a concurrent need for cholecystectomy with very large or multiple stones. The surgeon directly incises the CBD to remove the stones (the action), providing an alternative route for decompression (the rationale) (2).
Percutaneous Transhepatic Biliary Drainage (PTBD): For critically ill patients unfit for ERCP or surgery, a radiologist can insert a catheter through the skin and liver into the biliary system to drain infected bile (the action), serving as a life-saving temporizing measure to control sepsis (the rationale).35
Supportive & Symptomatic Care
Analgesia: Provide adequate pain relief, for example, with IV/IM Pethidine 50-100mg or Tramadol 50-100mg.
Antiemetics: Administer IV Metoclopramide 10mg or Ondansetron 4-8mg for nausea and vomiting.
Hydration: Maintain IV fluid infusion until the patient can tolerate oral intake.
Vitamin K: If the INR is prolonged, administer IV Vitamin K 10mg to reverse coagulopathy.
Key Nursing & Monitoring Instructions
Keep patient Nil By Mouth (NBM) in preparation for ERCP.36
Strict hourly monitoring of vital signs (BP, HR, RR, Temp, SpO2).
Maintain a strict input/output chart.
Inform the medical officer immediately if systolic BP drops below 90 mmHg, urine output is <0.5mL/kg/hr, or if there is any new confusion or deterioration in consciousness.
Long-Term Plan & Patient Education
Cholecystectomy: Following successful ERCP and resolution of the acute episode, patients with an intact gallbladder should be scheduled for a laparoscopic cholecystectomy, ideally during the same hospital admission or within 6 weeks (the action). This is to prevent recurrence of gallstone-related complications, as the source of the CBD stones remains (the rationale) (12).
Patient Education: Counsel the patient on the importance of the follow-up cholecystectomy. Explain the symptoms of recurrence (pain, fever, jaundice) and advise them to seek immediate medical attention if these occur.
When to Escalate
Call Your Senior (MO/Specialist) if:
The patient remains hypotensive despite initial fluid resuscitation.
The patient develops new signs of organ dysfunction (e.g., oliguria, respiratory distress, altered mentation).
The LFTs or inflammatory markers are worsening despite initial treatment.
There is any uncertainty about the diagnosis or management plan.
Referral Criteria:
Gastroenterology Team: For urgent ERCP.
General Surgery Team: For cholecystectomy and for surgical bile duct exploration if ERCP fails.
Intensive Care Unit (ICU) Team: For any patient with septic shock requiring vasopressor support or ventilatory assistance.
References
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Williams, E., Beckingham, I., El Sayed, G., Gurusamy, K., Sturgess, R., Webster, G., & Young, T. (2017).37 Updated guideline on the management of common bile duct stones (CBDS). Gut, 66(5), 765-782. https://gut.bmj.com/content/66/5/765
Canadian Association of General Surgeons. (n.d.). ACS Handbook CPG - Ch 8 - Biliary Colic and Cholecystitis. CAGS. https://cags-accg.ca/wp-content/uploads/2018/11/ACS-Handbook-CPG-Ch-8-Biliary-Colic-and-Cholecystitis.pdf
Cleveland Clinic. (2022). Choledocholithiasis: Symptoms, Causes & Treatment. https://my.clevelandclinic.org/health/diseases/24210-choledocholithiasis
DynaMed. (2024). Choledocholithiasis. https://www.dynamed.com/condition/choledocholithiasis
Kimura, Y., Takada, T., Kawarada, Y., Nimura, Y., Hirata, K., Sekimoto, M., ... & Wada, K. (2007).38 Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo Guidelines. Journal of Hepato-Biliary-Pancreatic Surgery, 14(1), 15-26. https://onlinelibrary.wiley.com/doi/full/10.1007/s00534-006-1152-y
NHS. (2021). Complications - Gallstones. https://www.nhs.uk/conditions/gallstones/complications/
Empendium. (n.d.). Choledocholithiasis. https://empendium.com/mcmtextbook/chapter/B31.II.6.2.2
Seo, Y. R., Lee, S. K., Kim, M. H., Lee, S. S., & Kim, D. G. (2004). Endoscopic retreatment of recurrent choledocholithiasis after sphincterotomy. Gut, 53(1), 118-121. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1774317/
American Academy of Family Physicians. (2004). Jaundice in the Adult Patient.39 American Family Physician, 69(2), 299-304. https://www.aafp.org/pubs/afp/issues/2004/0115/p299.html
Ministry of Health Malaysia. (2019). National Antibiotic Guideline 2019. Putrajaya: MOH. https://www.pharmacy.gov.my/v2/sites/default/files/document-upload/national-antibiotic-guideline-2019-3rd-edition.pdf
National Institute for Health and Care Excellence (NICE). (2014). Gallstone disease: diagnosis and management. NICE guideline [NG5]. https://www.nice.org.uk/guidance/cg188
