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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

  • The percentage of patients with choledocholithiasis (common bile duct stones) rises with age

  • 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

    • The Bile criteria have been proposed for the diagnoses of acute cholangitis:

      • Biliary imaging abnormalities

      • Inflammatory test abnormalities

      • Liver test abnormalities and exclusion of cholecystitis and acute pancreatitis

  • 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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