Choledocholithiasis

Choledocholithiasis is the presence of gallstone or gallstones within the common bile duct (CBD) ¹, ², ³, ⁴. “Choledocho” is the Latin term for the common bile duct and “lithiasis” means stones. Gallstone (cholelithiasis) may be made up of bile pigments or calcium and cholesterol salts. The common bile duct is a small tube that carries bile from the gallbladder to the duodenum (first segment of the small intestine). Bile is made in your liver and flows through the common hepatic duct and the cystic duct to the gallbladder, where it is stored. Your gallbladder is a small, pear-shaped organ on the right side of your abdomen, just beneath your liver. The gallbladder holds a digestive fluid called bile that’s released into your small intestine. When food is being digested, bile is released from the gallbladder and flows through the common bile duct (CBD), pancreas, and ampulla of Vater into the small intestine. Gallstones in the common bile duct pose a risk of obstructing the flow of bile. An obstruction can cause pain, inflammation and serious complications. Obstruction of the common bile duct may also lead to obstruction of the pancreatic duct because these ducts are usually connected. If the pancreatic duct is also obstructed, pancreatitis will likely develop.

If you have choledocholithiasis, you have at least one gallstone in your common bile duct (CBD). If a gallstone is very small, it may not cause you any problems and may even pass into your intestines. But if a gallstone becomes large enough or blocks your common bile duct, it’ll cause symptoms of severe constant pain and jaundice. A blockage in your common bile duct can cause inflammation, infection and life-threatening complications. Bile flow that is obstructed by stones within the common bile duct can lead to obstructive jaundice and possibly hepatitis. The stagnant bile can also lead to bactibilia (the presence of bacteria in gallbladder bile) and acute cholangitis. Acute cholangitis, also known as ascending cholangitis, is a life-threatening condition that is caused by an ascending bacterial infection of the biliary tree ⁵, ⁶. Delay in diagnosis and treatment can lead to septic shock. Cholangitis and sepsis are more common in patients with choledocholithiasis than other sources of bile duct obstruction because a bacterial biofilm typically covers common bile duct stones. The pancreatic duct joins the common bile duct near the duodenum, and therefore, the pancreas may also become inflamed by the obstruction of pancreatic enzymes. This is termed gallstone pancreatitis ⁷.

The incidence of choledocholithiasis in patients with gallstones (cholelithiasis) increases with age. Gallstones are hardened deposits of digestive fluid. Gallstones can vary in size and number. Gallstones (cholelithiasis) is more common in female patients, pregnant patients, older patients, and those with high serum lipid levels ⁸, ⁹. Gallstones are differentiated by their composition. Cholesterol stones are composed mainly of cholesterol, while black pigment stones are mainly made of pigment, and brown pigment stones are composed of a mix of pigment and bile lipids ¹⁰, ¹¹. Cholesterol stones are typically found in obese patients with low physical activity or patients that have recently intentionally lost weight. Black pigment stones are found in patients with cirrhosis, patients receiving total parental nutrition, and in those who have undergone an ileal resection. Cholesterol stones make up approximately 75% of the secondary common bile duct stones in the United States, while black pigment stones comprise the remainder ¹.

Choledocholithiasis is classified as primary or secondary according to stone origin ¹²:

• Primary choledocholithiasis refers to stones formed directly within the biliary tree,
• Secondary choledocholithiasis refers to stones ejected from the gallbladder.

Primary choledocholithiasis or primary common bile duct stones are usually brown pigment stones and is rare in Western populations ¹. Secondary choledocholithiasis stone composition parallels that of cholelithiasis, with cholesterol as the most common type ¹².

Your doctor will determine if treatment for choledocholithiasis is indicated based on your symptoms and the results of diagnostic testing. The goal of treatment is to relieve the blockage. The treatment for choledocholithiasis is the removal of the obstructing stones via endoscopic means.

Choledocholithiasis treatment may involve ¹³, ¹⁴, ¹⁵:

• Endoscopic retrograde cholangiopancreatography (ERCP) and a procedure called a sphincterotomy, which makes a surgical cut into the muscle in the common bile duct to allow stones to pass or be removed. Usually after removing gallstones from your bile ducts, doctors often recommend surgery to remove your gallbladder (cholecystectomy). This is to prevent more gallstones from exiting your gallbladder and causing choledocholithiasis again.
• Surgery to remove the gallbladder (cholecystectomy) and stones. Your doctor may recommend surgery to remove your gallbladder, since gallstones frequently recur. Once your gallbladder is removed, bile flows directly from your liver into your small intestine, rather than being stored in your gallbladder. You don’t need your gallbladder to live, and gallbladder removal doesn’t affect your ability to digest food, but it can cause diarrhea, which is usually temporary. A small number of people have softer and more frequent stools after gallbladder removal, because bile now flows into your duodenum more often. Changes in bowel habits are usually temporary; however, discuss them with your doctor.
  • Cholecystectomy in patients with choledocholithiasis remains controversial, but most experts recommend it. Arguments can be made against cholecystectomy in patients who cannot tolerate surgery well (eg, due to age, medical problems), as long as the patient is asymptomatic.
• Medications to dissolve gallstones. Oral dissolution therapy such as Ursodiol (Actigall) and chenodiol (Chenix) are medicines that contain bile acids that can break up gallstones. These medicines work best to break up small cholesterol stones. But it may take months or years of treatment to dissolve your gallstones in this way, and gallstones will likely form again if treatment is stopped. Sometimes medications don’t work. Medications for gallstones aren’t commonly used and are reserved for people who can’t undergo surgery.
• Shock wave lithotripsy. A doctor can use shock wave lithotripsy to blast gallstones into small pieces. Doctors use this procedure only rarely, and sometimes along with Ursodiol (Actigall).

Depending on your condition, you may need treatment before your gallstones can be removed, such as:

• Antibiotics to treat infection.
• Biliary drainage to remove backed-up bile.

Figure 1. Bile duct anatomy

Figure 2. Choledocholithiasis

How common is choledocholithiasis?

About 10% of people have gallstones, but most of them form in their gallbladder. About 1 in 7 people with gallstones will develop stones in the common bile duct. About 4.6% to 18.8% of people undergoing cholecystectomy have gallstones in their common bile duct. Gallstones will never bother most people. Only 20% of people with gallstones will have complications that require treatment.

What is choledocholithiasis vs. cholelithiasis?

You may have also heard the term “cholelithiasis,” which is similar. Cholelithiasis is the condition of having gallstones in your gallbladder. Gallstones may develop in your gallbladder or bile ducts, or both. A gallstone that develops in your gallbladder may also travel to your common bile duct.

What is biliary colic?

Biliary colic is intermittent pain from gallstones that obstruct your biliary system intermittently (off and on). This is more common with gallbladder stones, but can happen with choledocholithiasis if a gallstone obstructs your common bile duct off and on — for example, if it moves in and out of your duct.

Who is more likely to develop gallstones?

Certain groups of people have a higher risk of developing gallstones than others ¹⁶:

• Women are more likely to develop gallstones than men. Women who have extra estrogen in their body due to pregnancy, hormone replacement therapy, or birth control pills may be more likely to produce gallstones.
• Older people are more likely to develop gallstones. As you age, the chance that you’ll develop gallstones becomes higher.
• People with a family history of gallstones have a higher risk.
• American Indians have genes that raise the amount of cholesterol in their bile, and have the highest rate of gallstones in the United States.
• Mexican Americans are also at higher risk of developing gallstones.

You are more likely to develop gallstones if you have one of the following health conditions:

• Cirrhosis. Cirrhosis is severe scarring of the liver, a condition in which your liver slowly breaks down and stops working due to chronic, or long-lasting, injury
• Cholangitis or infections in the bile ducts, which can also be a complication of gallstones
• Hemolytic anemias, conditions in which red blood cells are continuously broken down, such as sickle cell anemia
• Some intestinal diseases that affect normal absorption of nutrients, such as Crohn’s disease
• High triglyceride levels (hypertriglyceridemia)
• Low HDL cholesterol
• Metabolic syndrome, which can also raise the risk of gallstone complications
• Diabetes and insulin resistance

You are more likely to develop gallstones if you:

• have obesity, especially if you are a woman
• have had fast weight loss, like from weight-loss surgery, also called metabolic and bariatric surgery
• have been on a diet high in calories and refined carbohydrates and low in fiber

Is choledocholithiasis an emergency?

A gallstone, or several, in your common bile duct isn’t necessarily an emergency, but it’s a risk. Smaller gallstones may pass safely through your common bile duct to your intestines and out of your body. The risk is that they’ll become stuck there and grow large enough over time to cause a blockage.

Because of this risk, healthcare providers prefer to treat common bile duct stones immediately when they find them. They’ll recommend an endoscopic procedure to examine and, most likely, remove the stones. That means a gastroenterologist will access your bile ducts via a catheter passed down your throat.

Choledocholithiasis causes

It’s not clear what causes gallstones to form. Doctors think gallstones may result when there’s too much of one of these — usually cholesterol, but sometimes bilirubin — and the excess materials turn into a kind of sediment. The sediment collects at the bottom of your gallbladder or your common bile duct and eventually hardens. The stones gradually grow as sediment continues to wash over them. This takes many years. Most gallstones form in your gallbladder and travel with the flow of bile into your common bile duct.

Probable causes gallstones to form ¹⁷:

• Your bile contains too much cholesterol. Normally, your bile contains enough chemicals to dissolve the cholesterol excreted by your liver. But if your liver excretes more cholesterol than your bile can dissolve, the excess cholesterol may form into crystals and eventually into stones.
• Your bile contains too much bilirubin. Bilirubin is a chemical that’s produced when your body breaks down red blood cells. Certain conditions cause your liver to make too much bilirubin, including liver cirrhosis, biliary tract infections and certain blood disorders. The excess bilirubin contributes to gallstone formation.
• Your gallbladder doesn’t empty correctly. If your gallbladder doesn’t empty completely or often enough, bile may become very concentrated, contributing to the formation of gallstones.

Choledocholithiasis occurs as a result of either the formation of stones in the common bile duct or the passage of gallstones that are formed in the gallbladder into the common bile duct. Bile stasis, the presence of bacteria in gall bladder bile (bactibilia), chemical imbalances, increased bilirubin excretion, pH imbalances, and the formation of sludge are some of the factors which lead to the formation of gallstones ¹. Less commonly, stones are formed in the intrahepatic biliary tree, termed primary hepatolithiasis, and may lead to choledocholithiasis. Stones that are too large to pass through the ampulla of Vater remain in the distal common bile duct, causing obstructive jaundice that may lead to pancreatitis, hepatitis, or cholangitis.

Risk factors are associated with choledocholithiasis

Factors that may increase your risk of gallstones include:

• Being female
• Being age 40 or older
• Being a Native American
• Being a Hispanic of Mexican origin
• Being overweight or obese
• Being sedentary
• Being pregnant
• Eating a high-fat diet
• Eating a high-cholesterol diet
• Eating a low-fiber diet
• Having a family history of gallstones
• Having diabetes
• Having certain blood disorders, such as sickle cell anemia or leukemia
• Losing weight very quickly
• Taking medications that contain estrogen, such as oral contraceptives or hormone therapy drugs
• Having liver disease

You may be more likely to get a gallstone in your common bile duct if you:

• Have chronic cholangitis. Choledocholithiasis is a major cause of cholangitis, but it can also work the other way around. If you have inflammation in your bile ducts from another cause, it may cause bile to slow and stall in your bile ducts, leading to sedimentation and gallstones.
• Have had gallstones before. Most people with gallstones don’t have complications, but people who’ve had them before are more likely to have them again. Even if you’ve had your gallbladder removed to treat gallstones, rarely, you may still develop new stones in your bile ducts.

Choledocholithiasis can occur in people who have had their gallbladder removed.

You may be more likely to have gallstones in general if you:

• Have high cholesterol. Most (75% of) gallstones are formed from excess cholesterol in your blood. Other bile ingredients (bile salts and lecithin) are supposed to help emulsify the cholesterol, but if there’s an imbalance between them, this doesn’t work.
• Have female hormones. Estrogen increases cholesterol, and progesterone slows gallbladder contractions, which increases sedimentation. Both hormones are higher during certain periods in female reproductive life, and hormone replacement therapy can also elevate them.

Choledocholithiasis pathophysiology

Bile made in the liver and stored in the gallbladder can lead to gallstone formation. In some patients with gallstones, the stones will pass from the gallbladder into the cystic duct and then into the common bile duct (CBD). Most of the choledocholithiasis cases are secondary to the gallstones passage from the gallbladder into the CBD ¹. Primary choledocholithiasis which is the formation of stones within the common bile duct (CBD) is seen less commonly. Primary choledocholithiasis occurs in the setting of bile stasis, which results in intraductal stone formation. The size of the bile duct increases with age. Older adults with dilated bile ducts and biliary diverticula are at risk for the formation of primary bile duct stones. Less common sources of choledocholithiasis include complicated Mirizzi syndrome or hepatolithiasis.

Choledocholithiasis prevention

As cholesterol gallstones are the most common type, you may be able to reduce your risk by reducing cholesterol in your blood through dietary and lifestyle changes. Doctors also recommend that you avoid “yo-yo” dieting and lose weight gradually. Losing too quickly can encourage gallstones.

You can reduce your risk of gallstones if you:

• Don’t skip meals. Try to stick to your usual mealtimes each day. Skipping meals or fasting can increase the risk of gallstones.
• Lose weight slowly. If you need to lose weight, go slow. Rapid weight loss can increase the risk of gallstones. Aim to lose 1 or 2 pounds (about 0.5 to 1 kilogram) a week.
• Eat more high-fiber foods. Include more fiber-rich foods in your diet, such as fruits, vegetables and whole grains.
• Maintain a healthy weight. Obesity and being overweight increase the risk of gallstones. Losing weight safely if you are overweight or have obesity. Work to achieve a healthy weight by reducing the number of calories you eat and increasing the amount of physical activity you get. Once you achieve a healthy weight, work to maintain that weight by continuing your healthy diet and continuing to exercise.

Choledocholithiasis signs and symptoms

Choledocholithiasis may cause no signs or symptoms. Unless your gallstones cause a blockage, you may never even know they’re there. If you do have symptoms, it means that a gallstone is blocking your common bile duct. The first sign of a blockage will be the symptoms of biliary colic. These can include ¹⁸, ¹⁹:

• Abdominal pain. Biliary pain occurs in episodes lasting from one to several hours, usually after a meal. It grows for the first 20 minutes and gradually declines after that. Most people feel it in their upper right abdomen, but it may also radiate to your right side or shoulder blade.
• Nausea and vomiting. Biliary colic is often accompanied by nausea and vomiting. You’ll notice that vomiting doesn’t relieve the pain, as it does with some other types, like migraines. If biliary colic isn’t as intense, you may only notice a general lack of appetite.
• Jaundice. Jaundice is the yellow discoloration of your skin, the whites of your eyes and body fluids. When bile backs up and leaks into your bloodstream, it may show up as a yellow tint to your skin or the whites of your eyes. It may also turn your pee a darker color. Jaundice can come and go, like biliary colic. But it’ll keep coming back until the blockage is cleared.
• Fever. Severe inflammation in your biliary system may cause a fever. Fever may also be a sign of an infection. When your bile ducts are blocked, bacteria aren’t flushed out as usual.

Choledocholithiasis complications

A gallstone that blocks your common bile duct (CBD) will cause bile to back up behind the blockage. This can affect all of the ducts and organs connected to it, including your gallbladder, pancreas and liver. It causes inflammation, breeds infection and can lead to long-term tissue damage.

Choledocholithiasis possible complications include:

• Blockage of the common bile duct. Gallstones can block the ducts through which bile flows from your gallbladder or liver to your small intestine. Severe pain, jaundice and bile duct infection can result.
• Infection. A blocked bile duct is an easy breeding ground for bacterial infections. An infection in your biliary system is very dangerous. It can spread to your liver and your bloodstream. An infection in your bloodstream (septicemia) can lead to life-threatening complications (sepsis).
• Cholangitis. Choledocholithiasis is the most common cause of cholangitis, inflammation and infection of your common bile duct. Backed-up bile causes your bile duct to swell, which further slows the flow of bile. Inflammation and infection can spread from your common bile duct to its branches, including those that run through your liver. It can cause your liver to swell.
• Cholecystitis. Cholecystitis is inflammation in your gallbladder. Bile backing up into your gallbladder will cause it to swell. This is painful and can stop it from functioning well and eventually damages the organ. This is the most common cause of gallbladder disease.
• Gallstone pancreatitis. Your bile ducts share the same exit channel into your intestines as your pancreas. Gallstones that block this common channel can also block secretions from your pancreas. These secretions, which contain very potent enzymes, will back up into your pancreas and cause severe inflammation and organ damage called pancreatitis. Pancreatitis causes intense, constant abdominal pain and usually requires hospitalization. Gallstones obstructing your bile ducts is the most common cause of non-alcohol-related pancreatitis.
• Gallbladder cancer. People with a history of gallstones have an increased risk of gallbladder cancer. But gallbladder cancer is very rare, so even though the risk of cancer is elevated, the likelihood of gallbladder cancer is still very small.

Choledocholithiasis diagnosis

Gallstones in your bile duct usually aren’t discovered unless they cause symptoms. If you have symptoms of biliary colic or jaundice, your doctor will investigate with blood tests and imaging tests. Blood tests will show the buildup of bile, and imaging will find the blockage.

Tests and procedures used to diagnose gallstones and complications of gallstones include:

• Abdominal ultrasound. This test is the one most commonly used to look for signs of gallstones. Abdominal ultrasound involves moving a device (transducer) back and forth across your stomach area. The transducer sends signals to a computer, which creates images that show the structures in your abdomen.
• Endoscopic ultrasound (EUS). Endoscopic ultrasound (EUS) test combines ultrasound technology with an upper endoscopy exam for a clearer picture of your bile ducts. It involves passing a tiny lighted camera on a tube (endoscope) down your throat and into your upper gastrointestinal tract. An ultrasound probe on the end of the endoscope sends out sound waves to produce images of your biliary system. This procedure can help identify smaller stones that may be missed on an abdominal ultrasound.
• Other imaging tests. Additional tests may include:
  • Oral cholecystography,
  • Hepatobiliary iminodiacetic acid (HIDA) scan,
  • Abdominal CT scan,
  • Magnetic resonance cholangiopancreatography (MRCP). Magnetic resonance cholangiopancreatography (MRCP) is a type of magnetic resonance imaging (MRI) that specifically visualizes the bile ducts. It’s noninvasive and creates very clear images of your biliary system, including the common bile duct. Your doctor might use this test first to find a suspected gallstone there. But if they’re already pretty sure it’s there, they might go straight to an endoscopic retrograde cholangiopancreatography (ERCP).
  • Endoscopic retrograde cholangiopancreatography (ERCP). ERCP (endoscopic retrograde cholangiopancreatography) test is a little more invasive, but it’s a useful one for finding gallstones because it can also be used to remove them. It combines X-rays and endoscopy. When the endoscope reaches the top of your small intestine, your doctor slides another, smaller tube into the first one to reach farther down into your bile ducts. They inject a special dye through the tube and then take video X-rays (fluoroscopy) as the dye travels through your ducts. When they find stones, they can be removed during the ERCP procedure. Doctors can attach special tools to the endoscope to break up and remove the stones when they find them. Sometimes, they make a surgical cut into the muscle of the duct to open it up and allow stones to pass. This is called a sphincterotomy. After removing gallstones from your bile ducts, doctors often recommend surgery to remove your gallbladder (cholecystectomy). This is to prevent more gallstones from exiting your gallbladder and causing choledocholithiasis again.
  • Percutaneous transhepatic cholangiogram (PTCA). A percutaneous transhepatic cholangiogram (PTCA) is an x-ray of the bile ducts. This test can help diagnose the cause of a bile duct blockage. Most of the time, percutaneous transhepatic cholangiogram (PTCA) is done after an endoscopic retrograde cholangiopancreatography (ERCP) test has been tried first. The PTCA may be done if an ERCP test cannot be performed or has failed to clear the blockage.
• Blood tests. Blood tests may reveal infection, jaundice, pancreatitis or other complications caused by gallstones. Blood tests may include:
  • Complete blood count (CBC).
  • Bilirubin test.
  • Pancreas enzymes (amylase or lipase).
  • Liver function tests.

Choledocholithiasis treatment

Your doctor will determine if treatment for choledocholithiasis is indicated based on your symptoms and the results of diagnostic testing. The goal of treatment is to relieve the blockage. The treatment for choledocholithiasis is the removal of the obstructing stones via endoscopic means.

Choledocholithiasis treatment may involve ¹³, ¹⁴, ¹⁵:

• Endoscopic retrograde cholangiopancreatography (ERCP) and a procedure called a sphincterotomy, which makes a surgical cut into the muscle in the common bile duct to allow stones to pass or be removed. Usually after removing gallstones from your bile ducts, doctors often recommend surgery to remove your gallbladder (cholecystectomy). This is to prevent more gallstones from exiting your gallbladder and causing choledocholithiasis again.
• Surgery to remove the gallbladder (cholecystectomy) and stones. Your doctor may recommend surgery to remove your gallbladder, since gallstones frequently recur. Once your gallbladder is removed, bile flows directly from your liver into your small intestine, rather than being stored in your gallbladder. You don’t need your gallbladder to live, and gallbladder removal doesn’t affect your ability to digest food, but it can cause diarrhea, which is usually temporary. A small number of people have softer and more frequent stools after gallbladder removal, because bile now flows into your duodenum more often. Changes in bowel habits are usually temporary; however, discuss them with your doctor.
  • Cholecystectomy in patients with choledocholithiasis remains controversial, but most experts recommend it. Arguments can be made against cholecystectomy in patients who cannot tolerate surgery well (eg, due to age, medical problems), as long as the patient is asymptomatic.
• Medications to dissolve gallstones. Oral dissolution therapy such as Ursodiol (Actigall) and chenodiol (Chenix) are medicines that contain bile acids that can break up gallstones. These medicines work best to break up small cholesterol stones. But it may take months or years of treatment to dissolve your gallstones in this way, and gallstones will likely form again if treatment is stopped. Sometimes medications don’t work. Medications for gallstones aren’t commonly used and are reserved for people who can’t undergo surgery.
• Shock wave lithotripsy. A doctor can use shock wave lithotripsy to blast gallstones into small pieces. Doctors use this procedure only rarely, and sometimes along with Ursodiol (Actigall).

Depending on your condition, you may need treatment before your gallstones can be removed, such as:

• Antibiotics to treat infection.
• Biliary drainage to remove backed-up bile.

There are no medications that will cure choledocholithiasis. However, a one-time dose of 50 mg to 100 mg rectal indomethacin can be used to prevent post-procedure pancreatitis if the pancreatic duct was manipulated during an ERCP ¹. Antibiotics are typically not needed for choledocholithiasis unless the patient also has associated cholecystitis or cholangitis ¹.

What are the complications of the treatment?

Treatment is simple and effective for most people. If you’re among the few who have complications afterward, these complications are also treatable. Between 5% and 25% of people may develop new gallstones in their bile ducts within 10 to 20 years. The risk is less if you have your gallbladder removed.

Short-term complications of endoscopic gallstone removal may include:

• Bleeding.
• Infection.
• Post-ERCP Pancreatitis. Post-ERCP pancreatitis is known to occur in less than 3% of patients ²⁰, ²¹, ³

Long-term complications after treatment may include:

• Gallstone recurrence. Even after removing all the gallstones in your bile ducts, it’s possible for new ones to form there later on. People who have had them are more likely to get them again.
• Bile duct fibrosis. Cutting into your bile duct can cause scarring of the tissue, and sometimes, scar tissue causes the passageway to narrow (biliary stricture). This can cause a different kind of obstruction in the common bile duct. It may require another procedure to treat it.

Choledocholithiasis prognosis

The prognosis of choledocholithiasis depends on the presence of complications and their severity  ¹. Approximately 45% of patients with choledocholithiasis remain asymptomatic. Of all patients who refuse surgery or are unfit to undergo surgery, only 55% experience varying degrees of complications  ¹. Less than 20% of patients experience recurrence of symptoms even after undergoing therapeutic procedures. If treatment is initiated at the right time, the prognosis is deemed favorable under general circumstances ¹.

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