Biliary Tract: Choledocholithiasis
Choledocholithiasis
Definition
- Stones Within CBD
Source
- Primary – Form Within CBD
- > 2 Years After Cholecystectomy Are Only Primary
- Secondary (Most Common) – Form Gallbladder & Migrate to CBD
Presentation
- Sx: RUQ Pain & N/V
- Most Are Clinically ASx
- Complications:
- Gallstone Pancreatitis
- Ascending Cholangitis
Diagnosis
- Labs: Elevated LFT’s
- Low Positive Predictive Value
- High Negative Predictive Value
- Best Tests:
- Highest Positive Predictive Value (PPV): Alkaline Phosphatase
- Highest Negative Predictive Value (NPV): GGT (96-97%)
- Highest Sensitivity: GGT
- Highest Specificity: Alkaline Phosphatase
- US: Dilated CBD
- Most Sensitive: MRCP or ERCP
MRCP Showing Stones in the Gallbladder & CBD 1
ASGE Clinical Predictors
- Predictors
- Very Strong:
- CBD Stone on US
- Clinical Ascending Cholangitis
- Bilirubin > 4 mg/dL
- Strong:
- Dilated CBD on US (> 6 mm with Gallbladder in Situ)
- Bilirubin 1.8-4.0 mg/dL
- Moderate:
- Abnormal LFT’s Other than Bilirubin
- Age > 55 Years
- Clinical Gallstone Pancreatitis
- Very Strong:
- Likelihood of Choledocholithiasis
- Presence of Any Very Strong Predictors: High (> 50%)
- Presence of Both Strong Predictors: High (> 50%)
- No Predictors Present: Low (< 10%)
- All Other Patients: Intermediate (10-50%)
Management
- Intermediate Likelihood/Dx Uncertain: MRCP vs Cholecystectomy with IOC
- High Likelihood/Dx Certain: ERCP & Elective Cholecystectomy (Same Hospitalization)
- If Diagnosed Intraoperatively Consider ERCP vs IOC
- 4-24% Risk of Biliary Complications if Cholecystectomy Deferred
- Timing of Cholecystectomy: Early (0-3 Days) Preferred
References
- Issa H, Al-Salem AH. Hepatobiliary Manifestations of Sickle Cell Anemia. Gastroenterology Res. 2010 Feb;3(1):1-8. (License: CC BY-2.0)