Choledocholithiasis: symptoms, causes and treatment (2023)

Overview

What is choledocholithiasis?

Choledocholithiasis is the condition of having a gallstone (or stones) in the common bile duct. “Choledocho” is the Latin term for the common bile duct and “lithiasis” means stones.gallstonesthey are pebble-like pieces of concentrated bile materials. They can develop anywhere bile flows.

What is choledocholithiasis vs. cholelithiasis?

You may have also heard the term "cholelithiasis," which is similar. Cholelithiasis is the condition of having gallstones in yourgallbladder. Gallstones may develop in the gallbladder orbile ducts, or both. A gallstone that develops in the gallbladder can also travel into the common bile duct.

What is choledocholithiasis versus biliary colic?

If you have choledocholithiasis, you have at least one gallstone in the common bile duct. If it is very small, it may not cause any problems and may even pass into the intestines. But if it grows large enough or blocks the common bile duct, it will cause symptoms of constant pain and jaundice.

Biliary colic is intermittent pain caused by gallstones that intermittently obstruct the biliary system. This is more common with gallbladder stones, but can occur with choledocholithiasis if a gallstone obstructs the common bile duct, for example by moving in and out of the duct.

Is choledocholithiasis an emergency?

A gallstone, or several, in the common bile duct is not necessarily an emergency, but it is a risk. Small gallstones can safely pass through the common bile duct into the intestines and out of the body. The risk is that they get stuck there and grow large enough over time to cause a crash.

Because of this risk, healthcare professionals prefer to treat common bile duct stones immediately when found. They will recommend an endoscopic procedure to examine and possibly remove the stones. This means that a gastroenterologist will access your bile ducts through a catheter inserted into your throat.

What can lead to choledocholithiasis?

If a gallstone remains in the common bile duct and grows large enough to block the flow of bile through the duct, it will endanger the entire biliary system. This is the network of organs and vessels that bile travels through. A blockage can cause inflammation, infection, and life-threatening complications.

How common is choledocholithiasis?

About 10% of people have gallstones, but most form in the gallbladder. About 15% of people with gallstones have them in the common bile duct. Gallstones will never bother most people. Only 20% of people with gallstones will have complications that require treatment.

Symptoms and Causes

What are the symptoms of choledocholithiasis?

You may not have any symptoms. Unless your gallstones are causing a blockage, you may not even know they're there. If you have symptoms, it means a stone is blocking the common bile duct. The first sign of obstruction will be symptoms of biliary colic. These may include:

• Dor abdominal. Biliary pain occurs in episodes that last from one to several hours, usually after a meal. It builds up in the first 20 minutes and gradually goes away after that. Most people feel it in the upper right part of the abdomen, but it can also radiate to the right side or shoulder.
• nausea and vomiting. Biliary colic is often accompanied by nausea and vomiting. You will notice that vomiting does not relieve pain as it does with other types, such as migraines. If the biliary colic isn't as severe, you may just notice a general lack of appetite.
• Jaundice. When bile backs up and leaks into the bloodstream, it can show up as a yellow tinge to the skin or whites of the eyes. It can also make your urine a darker color. Jaundice can come and go, like biliary colic. But it will keep coming back until the block is removed.
• Fever. Severe inflammation in the biliary system can cause fever. Fever can also be a sign of an infection. When your bile ducts are blocked, the bacteria are not removed as usual.

What are the possible complications of choledocholithiasis?

A gallstone blocking the common bile duct will cause bile to build up behind the blockage. This can affect all the ducts and organs connected to it, including the gallbladder, pancreas, and liver. It causes inflammation, generates infection and can cause long-term tissue damage. Complications include:

• Infection. A blocked bile duct is a breeding ground for bacterial infections. An infection in the biliary system is very dangerous. It can spread to the liver and bloodstream. A bloodstream infection (septicemia) can lead to life-threatening complications (WHY).
• cholangitis. Choledocholithiasis is the most common cause of cholangitis, inflammation and infection of the common bile duct. The accumulated bile causes the bile duct to swell, further slowing the flow of bile. Inflammation and infection can spread from the common bile duct to its branches, including those that pass through the liver. This can cause yourliver to swell.
• cholecystitis. Cholecystitis is inflammation of the gallbladder. Bile returning to the gallbladder will cause it to swell. This is painful and can prevent it from working properly and eventually damage the organ. This is the most common cause ofgallbladder disease.
• biliary pancreatitis. Your bile ducts share the same outlet channel in your intestines as yourpancreas. Gallstones that block this common channel can also block secretions from the pancreas. These secretions, which contain very powerful enzymes, back up into the pancreas and cause severe inflammation and damage to organs calledpancreatitis. Gallstones that obstruct the bile ducts are the most common cause of nonalcoholic pancreatitis.

What causes choledocholithiasis?

Your liver makes bile from materials it filters from your blood. These materials include cholesterol, bilirubin, bile salts, and lecithin. Gallstones occur when there is too much of one of these, usually cholesterol, but sometimes bilirubin, and the excess material turns into a kind of sludge.

Sediment collects at the bottom of the gallbladder or common bile duct and eventually hardens. The stones gradually grow larger as the sediment continues to wash them away. This takes many years. Most gallstones form in the gallbladder and travel with the flow of bile into the common bile duct.

What risk factors are associated with choledocholithiasis?

You are more likely to have a gallstone in the common bile duct if:

• have chronic cholangitis. Choledocholithiasis is one of the main causes of cholangitis, but it can also work the other way around. If you have inflammation in the bile ducts from another cause, this can cause bile to slow down and stop in the bile ducts, leading to sedimentation and gallstones.
• Have you had gallstones before?. Most people with gallstones do not have complications, but people who have had them before are more likely to get them again. Even if you have yourremoval of the gallbladderto treat gallstones, rarely, you can still develop new stones in the bile ducts.

You are more likely to have gallstones in general if you:

• Terhigh cholesterol. Most (75%) of gallstones are formed by excess cholesterol in the blood. Other bile ingredients (bile salts and lecithin) are supposed to help emulsify cholesterol, but if there is an imbalance between them, this won't work.
• have female hormones.estrogenincreases cholesterol, and progesterone slows gallbladder contractions, which increases sedimentation. Bothhormonesare larger during certain periods of female reproductive life, andHormone replacement therapyyou can also breed them.

Diagnosis and Tests

How is choledocholithiasis diagnosed?

Gallstones in the bile duct are usually not discovered unless they are causing symptoms. If you seek medical attention for symptoms of biliary colic or jaundice, your doctor will investigate with blood tests and imaging tests. Blood tests will show bile buildup and imaging tests will find the blockage.

What tests are used to diagnose choledocholithiasis?

Blood tests may include:

• Complete blood count(CBC).
• bilirubin test.
• Pancreas function tests.
• liver function tests.

Imaging tests may include:

• abdominal ultrasound. An ultrasound is a simple, non-invasive test that can give you some initial clues about your condition. It can reveal gallstones in the gallbladder, if any. It also does not visualize the common bile duct, but can show if its duct is dilated, indicating a blockage. You can also show shading where the blockage is.
• endoscopic ultrasoundThis test combines ultrasound technology with aupper endoscopyexam to get a clearer picture of your bile ducts. It involves passing a small lighted camera on a tube (endoscope) down the throat and into the upper gastrointestinal (GI) tract. An ultrasound probe at the end of the endoscope sends sound waves to produce images of your biliary system.
• CPRM. Magnetic resonance cholangiopancreatography (MRCP) is a type ofmagnetic resonancewhich specifically visualizes the bile ducts. It is non-invasive and creates very clear images of your biliary system, including the common bile duct. Your provider may use this test first to find a suspicious gallstone there. But if they're already sure it's there, they can go straight to an ERCP.
• CPRE. ERCP stands for endoscopic retrograde cholangiopancreatography. This test is a bit more invasive, but it is useful for finding gallstones because it can also be used to remove gallstones. Combines x-rays and endoscopy. When the endoscope reaches the top of the small intestine, the technician slides another, smaller tube into the first one to reach the bile ducts. They inject a special dye through the tube and then take video x-rays (fluoroscopia) as the dye travels through the ducts. When they find stones, they can treat them.

Management and Treatment

How do doctors remove gallstones in the common bile duct?

They are usually removed during an ERCP exam. Doctors can put special tools on the endoscope to break up and remove stones when they find them. Sometimes they make a surgical cut into the muscle of the duct to open it up and allow the stones to pass through. This is called a sphincterotomy.

Does choledocholithiasis require surgery?

The endoscopic procedure (ERCP) does not require cutting into your abdomen to access the bile ducts. However, after removing the gallstones from the bile ducts, doctors often recommendsurgery to remove the gallbladder. This is to prevent more gallstones from coming out of the gallbladder and causing choledocholithiasis again.

Will I need any other treatment?

Depending on your condition, you may need treatment before having your gallstones removed, such as:

• antibioticsto treat the infection.
• bile drainageto remove accumulated bile.

What are the complications of treatment?

Short-term complications of endoscopic gallstone removal may include:

• bleeding.
• Infection.
• Pancreatitis.

Long-term complications after treatment may include:

• Recurrence of gallstones. Even after all the gallstones in the bile ducts are removed, new ones may form later. People who have had them are more likely to get them again.
• bile duct fibrosis. Cutting the bile duct can leave scar tissue, and sometimes the scar tissue causes the duct to narrow (biliary stricture). This can cause a different type of blockage in the common bile duct. You may require another procedure to treat it.

Prevention

Can choledocholithiasis be prevented?

Since cholesterol gallstones are the most common type, you can reduce your risk by reducingblood cholesterolthrough diet and lifestyle changes. Health professionals also recommend avoiding "yo-yo" dieting and losing weight gradually. Losing too quickly can encourage gallstones.

Outlook / Forecast

What is the prognosis after treatment for choledocholithiasis?

Treatment is simple and effective for most people. If you are among the few who have complications afterward, these complications can also be treated. Between 5% and 25% of people can develop new gallstones in the bile ducts within 10 to 20 years. The risk is less if you have your gallbladder removed.

A note from the Cleveland Clinic

A gallstone attack can be intense and frightening, especially if you didn't know you had gallstones. The sooner you seek treatment, the sooner you will find relief. Always take biliary colic seriously, even if it goes away or is not yet severe. A blockage in the bile duct will only get worse until it is removed.