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Key Clinical Updates in Choledocholithiasis & Cholangitis

In acute calculous cholecystitis, predictors of concomitant choledocholithiasis are serum aminotransferase levels over three times the upper limit of normal, an alkaline phosphatase level above normal, a serum lipase over three times the upper limit of normal, a bilirubin of 1.8 mg/dL or more, and a bile duct diameter above 6 mm.

For bile duct stones 1 cm or more in diameter, endoscopic sphincterotomy followed by large balloon dilation has been recommended.

ESSENTIALS OF DIAGNOSIS

  • Often a history of biliary pain, which may be accompanied by jaundice.

  • Occasional patients present with painless jaundice.

  • Nausea and vomiting.

  • Cholangitis should be suspected with fever followed by hypothermia and gram-negative shock, jaundice, and leukocytosis.

  • Stones in bile duct most reliably detected by ERCP or EUS.

GENERAL CONSIDERATIONS

About 15% of patients with gallstones have choledocholithiasis (bile duct stones). The percentage rises with age, and the frequency in elderly people with gallstones may be as high as 50%. Bile duct stones usually originate in the gallbladder but may also form spontaneously in the bile duct after cholecystectomy. The risk is increased twofold in persons with a juxtapapillary duodenal diverticulum. Symptoms and possible cholangitis result if there is obstruction.

CLINICAL FINDINGS

A. Symptoms and Signs

A history of biliary pain or jaundice may be obtained. Biliary pain results from rapid increases in bile duct pressure due to obstructed bile flow. The features that suggest the presence of a bile duct stone are (1) frequently recurring attacks of right upper abdominal pain that is severe and persists for hours, (2) chills and fever associated with severe pain, and (3) a history of jaundice associated with episodes of abdominal pain (Table 16–9). The combination of right upper quadrant pain, fever (and chills), and jaundice represents Charcot triad and denotes the classic picture of acute cholangitis. The addition of altered mental status and hypotension (Reynolds pentad) signifies acute suppurative cholangitis and is an endoscopic emergency. According to the Tokyo guidelines (2006), the diagnosis of acute cholangitis is established by the presence of either (1) the Charcot triad or (2) two elements of the Charcot triad plus laboratory evidence of an inflammatory response (eg, elevated white blood cell count, C-reactive protein) and/or elevated liver biochemical test levels, and/or imaging evidence of biliary dilatation or obstruction.

Hepatomegaly may be present in calculous biliary obstruction, and tenderness is usually present in the right upper quadrant and epigastrium. Bile duct obstruction lasting more than 30 days results in liver damage leading to cirrhosis. Hepatic failure with portal hypertension occurs in untreated cases. In a population-based study from Denmark, acute cholangitis was reported to be a marker of occult gastrointestinal cancer.

B. Laboratory Findings

Acute obstruction of the bile duct typically produces a transient albeit striking increase in ...

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