Choledocholithiasis

Choledocholithiasis is a condition where gallstones get stuck in the common bile duct(CBD), the main tube that carries bile from the liver and gallbladder to the small intestine. While most gallstones form in the gallbladder, they can travel and get lodged in this larger duct, causing a blockage. This can lead to serious and painful complications if left untreated. 

Common causes

Most cases of choledocholithiasis occur when a gallstone formed in the gallbladder migrates into the common bile duct and gets lodged there. Less commonly, stones can form directly within the bile ducts, especially in people with liver disease or certain infections. 

  • Existing gallstones (cholelithiasis): Having stones in your gallbladder is the primary risk factor. Small stones are more likely to escape the gallbladder and cause a blockage in the common bile duct.

  • Previous gallbladder removal: Even after the gallbladder is removed, stones can form in the bile ducts themselves, which is known as "primary choledocholithiasis".

  • Bile duct abnormalities: A narrowing or scarring of the bile ducts can make it easier for stones or sludge to get stuck.

  • Certain medical conditions: People with liver cirrhosis or blood disorders like sickle cell anemia are more prone to forming certain types of gallstones.

  • Obesity and rapid weight loss: These can alter the composition of bile, increasing the risk of gallstone formation. 

Signs and symptoms

A person with bile duct stones may have no symptoms at all if the stone doesn't cause a blockage. However, if a blockage occurs, the symptoms can range from mild to severe. 

  • Biliary colic: This is a sudden, intense pain in the upper right or center of the abdomen, which can last from minutes to hours. The pain may radiate to the back or right shoulder blade and is often triggered by eating a heavy or fatty meal.

  • Nausea and vomiting: These are common and often accompany abdominal pain.

  • Jaundice: A yellowing of the skin and the whites of the eyes occurs when the blockage causes bile to back up into the liver and bloodstream. It can also cause dark urine and clay-colored stools.

  • Fever and chills: These are serious warning signs that can indicate an infection in the bile ducts, a condition called cholangitis.

  • Signs of pancreatitis: If the blockage occurs near the pancreatic duct, inflammation of the pancreas can occur, causing intense, persistent abdominal pain. 

Diagnosis

A doctor will use a combination of methods to diagnose choledocholithiasis and determine the best course of action.

  • Medical history and physical exam: The doctor will ask about your symptoms and check for tenderness in the upper right abdomen.

  • Blood tests: Tests can check for liver function abnormalities (elevated bilirubin, alkaline phosphatase) and signs of infection.

  • Imaging tests:

    • Abdominal ultrasound: Often the first test, it can detect gallstones in the gallbladder but is less accurate for visualizing stones in the common bile duct.

    • Magnetic resonance cholangiopancreatography (MRCP): A highly accurate, non-invasive MRI scan that produces detailed images of the bile ducts.

    • Endoscopic ultrasound (EUS): A highly sensitive procedure where a special endoscope is used to get very close to the common bile duct to look for stones.

  • ERCP (Endoscopic Retrograde Cholangiopancreatography): This is a specialized procedure that is both diagnostic(to assess) and therapeutic(to treat). An endoscope is passed down the throat and into the common bile duct. Dye is injected to highlight the ducts and identify the stones. 

Treatment

Unlike gallstones that stay in the gallbladder, bile duct stones almost always require treatment to avoid dangerous complications like infection or pancreatitis. 

  • Endoscopic Retrograde Cholangiopancreatography (ERCP): The most common treatment, especially if the diagnosis is clear. During the ERCP procedure, the doctor can perform a sphincterotomy (a small incision in the duct) to help stones pass or use a tiny basket or balloon to remove them. Larger stones can be broken up first.

  • Laparoscopic surgery: In some cases, a surgeon can clear the stones from the bile duct during a laparoscopic (minimally invasive) cholecystectomy, the surgery to remove the gallbladder.

  • Surgical removal of the gallbladder (cholecystectomy): To prevent future stone migration, doctors often recommend removing the gallbladder, especially after a successful ERCP.

  • Antibiotics: If an infection (cholangitis) is present, IV antibiotics will be given to control the infection before or during the stone removal.

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