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Choledocholithiasis & Cholangitis

For further information, see CMDT Part 16-23: Choledocholithiasis & Cholangitis

Key Features

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, which may be followed by hypothermia, jaundice, leukocytosis and gram-negative shock

  • Stones in common bile duct most reliably detected by endoscopic retrograde cholangiopancreatography (ERCP) or endoscopic ultrasonography

General Considerations

  • Bile duct stones usually originate in the gallbladder but may also form spontaneously in the common bile duct after cholecystectomy

  • Symptoms, including those of cholangitis, result if there is obstruction

  • Biliary pain results from rapid increases in bile duct pressure due to obstructed bile flow

Demographics

  • About 15% of patients with gallstones have choledocholithiasis (common bile duct stones)

  • The percentage rises with age, and the frequency in elderly people with gallstones may be as high as 50%

Clinical Findings

Symptoms and Signs

  • See Table 16–9

  • Biliary pain with jaundice in choledocholithiasis

  • Frequently recurring attacks of right upper abdominal pain that is severe and persists for hours

  • Chills and fever associated with severe pain in acute cholangitis

  • Charcot triad (pain, fever [and chills], and jaundice) is characteristic of acute cholangitis

  • Additional symptoms of altered mental status and hypotension (Reynold pentad) signifies acute suppurative cholangitis and is an endoscopic or surgical emergency

  • According to the Tokyo guidelines, either of the following needs to be present to establish the diagnosis of acute cholangitis:

    • The full Charcot triad or

    • Two elements of the Charcot triad plus laboratory evidence of an inflammatory response (eg, elevated WBC count, C-reactive protein), elevated liver test results, and imaging evidence of biliary dilatation or a cause of obstruction

  • Hepatomegaly may be present in calculous biliary obstruction, and tenderness is usually present in the right upper quadrant and epigastrium

Table 16–9.Diseases of the biliary tract.
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Table 16–9. Diseases of the biliary tract.
  Clinical Features Laboratory Features Diagnosis Treatment
Asymptomatic gallstones Asymptomatic Normal Ultrasonography None
Symptomatic gallstones Biliary pain Normal Ultrasonography Laparoscopic cholecystectomy
Cholesterolosis of gallbladder Usually asymptomatic Normal Oral cholecystography None
Adenomyomatosis May cause biliary pain Normal Oral cholecystography Laparoscopic cholecystectomy if symptomatic
Porcelain gallbladder Usually asymptomatic, high risk of gallbladder cancer Normal Radiograph or CT Laparoscopic cholecystectomy
Acute cholecystitis Epigastric or right upper quadrant pain, nausea, vomiting, fever, Murphy sign Leukocytosis Ultrasonography, HIDA scan Antibiotics, laparoscopic cholecystectomy
Chronic cholecystitis Biliary pain, constant epigastric or right upper quadrant pain, nausea Normal Ultrasonography (stones), oral cholecystography (nonfunctioning gallbladder) Laparoscopic cholecystectomy
Choledocholithiasis Asymptomatic or biliary pain, jaundice, fever; gallstone pancreatitis Cholestatic liver biochemical tests; leukocytosis and positive blood cultures in cholangitis; elevated amylase and lipase in pancreatitis Ultrasonography (dilated ducts), ...

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