Choledocolithiasis
Pager goes off and on the other line is the story of any number of patients. Young person with cholecystitis ERCP or OR? Patient with fever chills and elevated transaminases what next? Is that a dilated CBD? Though they are different situations the question at the heart of the consults is the same.. Is this choledocolithiasis and what do we do next?
Choledocolithiasis is the presence of stones in the bile duct. As with stones in the gallbladder stones in the bile duct isn’t unusual and stones commonly pass through the common bile duct into the duodenum without issue and even remain in the common. If stones get stuck or cause a blockage of the biliary tree the consequences can be dire.
Presentations: Clinical presentation can range from mild and intermittent to severe!
Physical Exam: If mild can have no physical exam findings. Obstruction can develop over a long period of time and be intermittent resulting in pruritis and jaundice with mild abdominal pain which progresses. Sudden obstruction with bacterial infection can manifest with Charcots triad(Fever, Jaundice, Abdominal Pain) or Reynolds Pentad (Fever, Jaundice, abdominal pain, shock and altered mental status)
Laboratory studies: Typical findings are elevated bilirubin and alkaline phosphatase. Bilirubin correlates with the degree of obstruction whereas Alk Phos elevation has no correlation with amount of blockage. AST and ALT can also be elevated. Other important labs to consider are CBC (clues on infection or hemolysis), Lipase (Acute pancreatitis), Renal Panel and Lactic acid.
Imaging: Any time a patient comes in with elevated transaminases of unknown etiology or with labs suggesting obstruction of a biliary tree imaging is needed to further determine possible causes and to guide the next steps in care. But which do you get and when?
Determining Probability:
How do you assess probability? Decision making is easy when the patient has ascending cholangitis or has a large dilated common bile duct but what about those in-between cases. Luckily ASGE has great guidelines on how to assess probability.
Patients with a low probability(<10%) should have MRCP or EUS prior to considering ERCP
Patients with 1 strong predictor or moderate predictors are considered intermediate risk (10-50%) should also undergo MRCP or EUS
Patients with any very strong or both strong predictors (>50%) should proceed to ERCP if suitable candidate for the procedure
Important Considerations:
Is the patient suitable for ERCP. This includes clinical stability, accepting of risks of procedure and will anatomy allow.
Have they had Roux EN-Y or Billiroth II procedure?
Is there another process to consider such as a mass, mirizzi’s syndrome, acute pancreatitis or others that may effect diagnostic studies or list interventions
Choledocolithiasis is a common biliary problem. Limiting procedures to those who would likely benefit is important as it lists risks associated with ERCP and anesthesia. It is also important to identify who needs a ERCP which can be a life saving procedure.
A lot more to talk about on this topic including in depth details on ERCP itself as well as surgical decision making: Check out the ASGE Guidelines for endoscopic role in Choledocolithiasis and SAGES guidelines on cholelithiasis
If you find yourself near endoscopy room 7 you can always count on our very own Dr. Smith collecting stones and opening ducts. He is a great resource for everything ERCP and advanced endoscopy
