Choledocholithiasis: Evaluation, Treatment, and Outcomes

Abstract

Choledocholithiasis occurs in up to approximately 20% of patients with cholelithiasis. A majority of stones form in the gallbladder and then pass into the common bile duct, where they generate symptoms, due to biliary obstruction. Confirmatory diagnosis of choledocholithiasis is made with advanced imaging, including magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography (ERCP). Treatment varies locally; however, ERCP with sphincterotomy is most commonly employed with a high degree of success. Difficult anatomy and difficult stone burden require advanced surgical, endoscopic, and percutaneous techniques to extract or expel biliary stones. Knowledge of these treatment strategies will optimize outcomes.

Keywords

choledocholithiasis - diagnosis - endoscopy - percutaneous - interventional radiology - treatment

• References

• 1 Williams EJ, Green J, Beckingham I, Parks R, Martin D, Lombard M ; British Society of Gastroenterology. Guidelines on the management of common bile duct stones (CBDS). Gut 2008; 57 (7) 1004-1021
• 2 Gurusamy KS, Giljaca V, Takwoingi Y , et al. Ultrasound versus liver function tests for diagnosis of common bile duct stones. Cochrane Database Syst Rev 2015; 2 (2) CD011548
• 3 European Association for the Study of the Liver (EASL). Electronic address: [e-mail]. EASL Clinical Practice Guidelines on the prevention, diagnosis and treatment of gallstones. J Hepatol 2016; 65 (1) 146-181
• 4 Yadav D, Agarwal N, Pitchumoni CS. A critical evaluation of laboratory tests in acute pancreatitis. Am J Gastroenterol 2002; 97 (6) 1309-1318
• 5 Qiao T, Ma RH, Luo XB, Yang LQ, Luo ZL, Zheng PM. The systematic classification of gallbladder stones. PLoS ONE 2013; 8 (10) e74887
• 6 Portincasa P, Moschetta A, Palasciano G. Cholesterol gallstone disease. Lancet 2006; 368 (9531) 230-239
• 7 Brink MA, Slors JF, Keulemans YC , et al. Enterohepatic cycling of bilirubin: a putative mechanism for pigment gallstone formation in ileal Crohn's disease. Gastroenterology 1999; 116 (6) 1420-1427
• 8 Flass T, Narkewicz MR. Cirrhosis and other liver disease in cystic fibrosis. J Cyst Fibros 2013; 12 (2) 116-124
• 9 Vítek L, Carey MC. New pathophysiological concepts underlying pathogenesis of pigment gallstones. Clin Res Hepatol Gastroenterol 2012; 36 (2) 122-129
• 10 Stinton LM, Myers RP, Shaffer EA. Epidemiology of gallstones. Gastroenterol Clin North Am 2010; 39 (2) 157-169 , vii
• 11 Kaufman HS, Magnuson TH, Lillemoe KD, Frasca P, Pitt HA. The role of bacteria in gallbladder and common duct stone formation. Ann Surg 1989; 209 (5) 584-591 , discussion 591–592
• 12 Einstein DM, Lapin SA, Ralls PW, Halls JM. The insensitivity of sonography in the detection of choledocholithiasis. AJR Am J Roentgenol 1984; 142 (4) 725-728
• 13 Cronan JJ. US diagnosis of choledocholithiasis: a reappraisal. Radiology 1986; 161 (1) 133-134
• 14 Maple JT, Ben-Menachem T, Anderson MA , et al; ASGE Standards of Practice Committee. The role of endoscopy in the evaluation of suspected choledocholithiasis. Gastrointest Endosc 2010; 71 (1) 1-9
• 15 Hunt DR. Common bile duct stones in non-dilated bile ducts? An ultrasound study. Australas Radiol 1996; 40 (3) 221-222
• 16 Gibson RN, Vincent JM, Speer T, Collier NA, Noack K. Accuracy of computed tomographic intravenous cholangiography (CT-IVC) with iotroxate in the detection of choledocholithiasis. Eur Radiol 2005; 15 (8) 1634-1642
• 17 Cabada Giadás T, Sarría Octavio de Toledo L, Martínez-Berganza Asensio MT , et al. Helical CT cholangiography in the evaluation of the biliary tract: application to the diagnosis of choledocholithiasis. Abdom Imaging 2002; 27 (1) 61-70
• 18 Vitellas KM, Keogan MT, Spritzer CE, Nelson RC. MR cholangiopancreatography of bile and pancreatic duct abnormalities with emphasis on the single-shot fast spin-echo technique. Radiographics 2000; 20 (4) 939-957 , quiz 1107–1108, 1112
• 19 Baron RL, Tublin ME, Peterson MS. Imaging the spectrum of biliary tract disease. Radiol Clin North Am 2002; 40 (6) 1325-1354
• 20 Choi IY, Yeom SK, Cha SH , et al. Diagnosis of biliary stone disease: T1-weighted magnetic resonance cholangiography with Gd-EOB-DTPA versus T2-weighted magnetic resonance cholangiography. Clin Imaging 2014; 38 (2) 164-169
• 21 Sugiyama M, Atomi Y, Hachiya J. Magnetic resonance cholangiography using half-Fourier acquisition for diagnosing choledocholithiasis. Am J Gastroenterol 1998; 93 (10) 1886-1890
• 22 Giljaca V, Gurusamy KS, Takwoingi Y , et al. Endoscopic ultrasound versus magnetic resonance cholangiopancreatography for common bile duct stones. Cochrane Database Syst Rev 2015; 2 (2) CD011549
• 23 Verma D, Kapadia A, Eisen GM, Adler DG. EUS vs MRCP for detection of choledocholithiasis. Gastrointest Endosc 2006; 64 (2) 248-254
• 24 Williams EJ, Taylor S, Fairclough P , et al. Risk factors for complication following ERCP; results of a large-scale, prospective multicenter study. Endoscopy 2007; 39 (9) 793-801
• 25 Bergman JJ, Rauws EA, Fockens P , et al. Randomised trial of endoscopic balloon dilation versus endoscopic sphincterotomy for removal of bile duct stones. Lancet 1997; 349 (9059) 1124-1129
• 26 Freeman ML, Nelson DB, Sherman S , et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med 1996; 335 (13) 909-918
• 27 Massarweh NN, Devlin A, Elrod JA, Symons RG, Flum DR. Surgeon knowledge, behavior, and opinions regarding intraoperative cholangiography. J Am Coll Surg 2008; 207 (6) 821-830
• 28 Gurusamy KS, Giljaca V, Takwoingi Y , et al. Endoscopic retrograde cholangiopancreatography versus intraoperative cholangiography for diagnosis of common bile duct stones. Cochrane Database Syst Rev 2015; 2 (2) CD010339
• 29 Machi J, Tateishi T, Oishi AJ , et al. Laparoscopic ultrasonography versus operative cholangiography during laparoscopic cholecystectomy: review of the literature and a comparison with open intraoperative ultrasonography. J Am Coll Surg 1999; 188 (4) 360-367
• 30 Machi J, Johnson JO, Deziel DJ , et al. The routine use of laparoscopic ultrasound decreases bile duct injury: a multicenter study. Surg Endosc 2009; 23 (2) 384-388
• 31 Tranter SE, Thompson MH. Comparison of endoscopic sphincterotomy and laparoscopic exploration of the common bile duct. Br J Surg 2002; 89 (12) 1495-1504
• 32 Martin DJ, Vernon DR, Toouli J. Surgical versus endoscopic treatment of bile duct stones. Cochrane Database Syst Rev 2006; 2 (2) CD003327
• 33 Cuschieri A, Lezoche E, Morino M , et al. E.A.E.S. multicenter prospective randomized trial comparing two-stage vs single-stage management of patients with gallstone disease and ductal calculi. Surg Endosc 1999; 13 (10) 952-957
• 34 Rhodes M, Sussman L, Cohen L, Lewis MP. Randomised trial of laparoscopic exploration of common bile duct versus postoperative endoscopic retrograde cholangiography for common bile duct stones. Lancet 1998; 351 (9097) 159-161
• 35 Richardson JF, Lee JG, Smith BR, Nguyen B, Pham KP, Nguyen NT. Laparoscopic transgastric endoscopy after Roux-en-Y gastric bypass: case series and review of the literature. Am Surg 2012; 78 (10) 1182-1186
• 36 Arregui ME, Davis CJ, Arkush AM, Nagan RF. Laparoscopic cholecystectomy combined with endoscopic sphincterotomy and stone extraction or laparoscopic choledochoscopy and electrohydraulic lithotripsy for management of cholelithiasis with choledocholithiasis. Surg Endosc 1992; 6 (1) 10-15
• 37 Koo KP, Traverso LW. Do preoperative indicators predict the presence of common bile duct stones during laparoscopic cholecystectomy?. Am J Surg 1996; 171 (5) 495-499
• 38 Perissat J, Huibregtse K, Keane FB, Russell RC, Neoptolemos JP. Management of bile duct stones in the era of laparoscopic cholecystectomy. Br J Surg 1994; 81 (6) 799-810
• 39 Geron N, Reshef R, Shiller M, Kniaz D, Eitan A. The role of endoscopic retrograde cholangiopancreatography in the laparoscopic era. Surg Endosc 1999; 13 (5) 452-456
• 40 Tham TC, Lichtenstein DR, Vandervoort J , et al. Role of endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis in patients undergoing laparoscopic cholecystectomy. Gastrointest Endosc 1998; 47 (1) 50-56
• 41 Freeman ML. Complications of endoscopic retrograde cholangiopancreatography: avoidance and management. Gastrointest Endosc Clin N Am 2012; 22 (3) 567-586
• 42 Wojtun S, Gil J, Gietka W, Gil M. Endoscopic sphincterotomy for choledocholithiasis: a prospective single-center study on the short-term and long-term treatment results in 483 patients. Endoscopy 1997; 29 (4) 258-265
• 43 Hawes RH, Cotton PB, Vallon AG. Follow-up 6 to 11 years after duodenoscopic sphincterotomy for stones in patients with prior cholecystectomy. Gastroenterology 1990; 98 (4) 1008-1012
• 44 García-Vila JH, Redondo-Ibáñez M, Díaz-Ramón C. Balloon sphincteroplasty and transpapillary elimination of bile duct stones: 10 years' experience. AJR Am J Roentgenol 2004; 182 (6) 1451-1458
• 45 Doi S, Yasuda I, Mukai T , et al. Comparison of long-term outcomes after endoscopic sphincterotomy versus endoscopic papillary balloon dilation: a propensity score-based cohort analysis. J Gastroenterol 2013; 48 (9) 1090-1096
• 46 Okuno M, Iwashita T, Yasuda I , et al. Percutaneous transgallbladder rendezvous for enteroscopic management of choledocholithiasis in patients with surgically altered anatomy. Scand J Gastroenterol 2013; 48 (8) 974-978
• 47 Patel M, Levitin A, Chahal P. Hybrid percutaneous-endoscopic drainage of cholelithiasis and choledocholithiasis. Gastrointest Endosc 2015; 81 (4) 1013-1014
• 48 Banerjee B, Harshfield DL, Teplick SK. Percutaneous transcholecystic approach to the rendezvous procedure when transhepatic access fails. J Vasc Interv Radiol 1994; 5 (6) 895-898
• 49 Matsubayashi H, Maeda A, Fukutomi A, Ono H. A case of choledocholithiasis treated by parallel cannulation along with PTGBD rendezvous. Can J Gastroenterol 2009; 2 (1) 36-38
• 50 Kato H, Tsutsumi K, Harada R, Okada H, Yamamoto K. Short double-balloon enteroscopy is feasible and effective for endoscopic retrograde cholangiopancreatography in patients with surgically altered gastrointestinal anatomy. Dig Endosc 2014; 26 (Suppl. 02) 130-135
• 51 Moreels TG. Altered anatomy: enteroscopy and ERCP procedure. Best Pract Res Clin Gastroenterol 2012; 26 (3) 347-357
• 52 Inamdar S, Slattery E, Sejpal DV , et al. Systematic review and meta-analysis of single-balloon enteroscopy-assisted ERCP in patients with surgically altered GI anatomy. Gastrointest Endosc 2015; 82 (1) 9-19
• 53 Wagh MS, Draganov PV. Prospective evaluation of spiral overtube-assisted ERCP in patients with surgically altered anatomy. Gastrointest Endosc 2012; 76 (2) 439-443
• 54 Stefanidis G, Christodoulou C, Manolakopoulos S, Chuttani R. Endoscopic extraction of large common bile duct stones: a review article. World J Gastrointest Endosc 2012; 4 (5) 167-179
• 55 Sorbi D, Van Os EC, Aberger FJ , et al. Clinical application of a new disposable lithotripter: a prospective multicenter study. Gastrointest Endosc 1999; 49 (2) 210-213
• 56 Cipolletta L, Costamagna G, Bianco MA , et al. Endoscopic mechanical lithotripsy of difficult common bile duct stones. Br J Surg 1997; 84 (10) 1407-1409
• 57 Chang WH, Chu CH, Wang TE, Chen MJ, Lin CC. Outcome of simple use of mechanical lithotripsy of difficult common bile duct stones. World J Gastroenterol 2005; 11 (4) 593-596
• 58 Arya N, Nelles SE, Haber GB, Kim YI, Kortan PK. Electrohydraulic lithotripsy in 111 patients: a safe and effective therapy for difficult bile duct stones. Am J Gastroenterol 2004; 99 (12) 2330-2334
• 59 Hochberger J, Bayer J, May A , et al. Laser lithotripsy of difficult bile duct stones: results in 60 patients using a rhodamine 6G dye laser with optical stone tissue detection system. Gut 1998; 43 (6) 823-829
• 60 Mondet AF. Technic of blood extraction of calculi in residual lithasis of the choledochus [in Spanish]. Bol Trab Soc Cir B Aires 1962; 46: 278-290
• 61 Burhenne HJ. Garland lecture. Percutaneous extraction of retained biliary tract stones: 661 patients. AJR Am J Roentgenol 1980; 134 (5) 889-898
• 62 Dotter CT, Bilbao MK, Katon RM. Percutaneous transhepatic gallstone removal by needle tract. Radiology 1979; 133 (1) 242-243
• 63 Perez MR, Oleaga JA, Freiman DB, McLean GL, Ring EJ. Removal of a distal common bile duct stone through percutaneous transhepatic catheterization. Arch Surg 1979; 114 (1) 107-109
• 64 Thistle JL, May GR, Bender CE , et al. Dissolution of cholesterol gallbladder stones by methyl tert-butyl ether administered by percutaneous transhepatic catheter. N Engl J Med 1989; 320 (10) 633-639
• 65 Kim G, Malayaman SN, Green MS. Use of methyl tert-butyl ether for the treatment of refractory intrahepatic biliary strictures and bile casts: a modern perspective. Case Rep Surg 2015; 2015: 408175
• 66 Yasuda H, Takada T, Kawarada Y , et al. Unusual cases of acute cholecystitis and cholangitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007; 14 (1) 98-113
• 67 Cheon YK, Cho YD, Moon JH, Lee JS, Shim CS. Evaluation of long-term results and recurrent factors after operative and nonoperative treatment for hepatolithiasis. Surgery 2009; 146 (5) 843-853
• 68 Atar E, Neiman C, Ram E, Almog M, Gadiel I, Belenky A. Percutaneous trans-papillary elimination of common bile duct stones using an existing gallbladder drain for access. Isr Med Assoc J 2012; 14 (6) 354-358
• 69 Kint JF, van den Bergh JE, van Gelder RE , et al. Percutaneous treatment of common bile duct stones: results and complications in 110 consecutive patients. Dig Surg 2015; 32 (1) 9-15
• 70 Cannavale A, Bezzi M, Cereatti F , et al. Combined radiological-endoscopic management of difficult bile duct stones: 18-year single center experience. Therap Adv Gastroenterol 2015; 8 (6) 340-351
• 71 Nagashima I, Takada T, Shiratori M, Inaba T, Okinaga K. Percutaneous transhepatic papillary balloon dilation as a therapeutic option for choledocholithiasis. J Hepatobiliary Pancreat Surg 2004; 11 (4) 252-254
• 72 García-García L, Lanciego C. Percutaneous treatment of biliary stones: sphincteroplasty and occlusion balloon for the clearance of bile duct calculi. AJR Am J Roentgenol 2004; 182 (3) 663-670
• 73 Minami A, Nakatsu T, Uchida N , et al. Papillary dilation vs sphincterotomy in endoscopic removal of bile duct stones. A randomized trial with manometric function. Dig Dis Sci 1995; 40 (12) 2550-2554
• 74 Szulman C, Giménez M, Sierre S. Antegrade papillary balloon dilation for extrahepatic bile duct stone clearance: lessons learned from treating 300 patients. J Vasc Interv Radiol 2011; 22 (3) 346-353
• 75 Ozcan N, Kahriman G, Mavili E. Percutaneous transhepatic removal of bile duct stones: results of 261 patients. Cardiovasc Intervent Radiol 2012; 35 (3) 621-627
• 76 Ray AA, Davies ET, Duvdevani M, Razvi H, Denstedt JD. The management of treatment-resistant biliary calculi using percutaneous endourologic techniques. Can J Surg 2009; 52 (5) 407-412
• 77 Cheung MT, Wai SH, Kwok PC. Percutaneous transhepatic choledochoscopic removal of intrahepatic stones. Br J Surg 2003; 90 (11) 1409-1415
• 78 Sullivan KL, Bagley Jr DH, Gordon SJ , et al. Transhepatic laser lithotripsy of choledocholithiasis: initial clinical experience. J Vasc Interv Radiol 1991; 2 (3) 387-391
• 79 Burton KE, Picus D, Hicks ME , et al. Fragmentation of biliary calculi in 71 patients by use of intracorporeal electrohydraulic lithotripsy. J Vasc Interv Radiol 1993; 4 (2) 251-256
• 80 Hwang MH, Tsai CC, Mo LR , et al. Percutaneous choledochoscopic biliary tract stone removal: experience in 645 consecutive patients. Eur J Radiol 1993; 17 (3) 184-190
• 81 Yeh YH, Huang MH, Yang JC, Mo LR, Lin J, Yueh SK. Percutaneous trans-hepatic cholangioscopy and lithotripsy in the treatment of intrahepatic stones: a study with 5 year follow-up. Gastrointest Endosc 1995; 42 (1) 13-18
• 82 Stokes KR, Falchuk KR, Clouse ME. Biliary duct stones: update on 54 cases after percutaneous transhepatic removal. Radiology 1989; 170 (3, Pt 2): 999-1001
• 83 Bonnel DH, Liguory CE, Cornud FE, Lefebvre JF. Common bile duct and intrahepatic stones: results of transhepatic electrohydraulic lithotripsy in 50 patients. Radiology 1991; 180 (2) 345-348
• 84 Oh HC, Lee SK, Lee TY , et al. Analysis of percutaneous transhepatic cholangioscopy-related complications and the risk factors for those complications. Endoscopy 2007; 39: 731-736