Choledocholithiasis is one of the main causes for Obstructive Jaundice.In this ppt presentation, I have discussed the etiology, clinical features, complications, investigations and management of Choledocholithiasis. I have also included a mindmap and 2 algorithms for Choledocholithiasis. I hope you will find it very useful and interesting.
A 40-year-old female presents with a 24 hour history of right upper
quadrant (RUQ) and epigastric pain, associated with nausea and
vomiting. She has had similar pain in the past, particularly after
eating fatty foods. According to her family, over the last few hours,
the patient has become slightly confused. Past medical history is
O/E: She is moderately tender in the RUQ to deep palpation. She has
slight scleral icterus. She has noted dark- coloured urine. The
remainder of her abdominal exam is negative.
Vitals: BP-90/60 mms of Hg; PR-110/mt; RR-16/mt;T:102*F
Classical Clinical Vignette
TWBC- 15,000/μL(4 to 11,000/μL),
Total bilirubin-4mgm/dl(0.1 to 1.2mgm/dl) Direct bili- 3mgm/dl
ALP- 350μ/L (33-131μ/L); GGT- 330μ/L (8-88μ/L)
AST- 300μ/L(5-35μ/L); ALT- 280μ/L(7-56μ/L)
Sr Amylase- 100μ/L( 30-110μ/L)
Urine is positive for bilirubin
It is stones in the CBD and biliary tree.
Primary—Rare 5%—brown pigment stones. They are formed in
CBD and biliary tree itself, and are multiple, often sludge like,
commonly pigment or mixed type, extends into hepatic ducts.
Causes: Biliary stasis, biliary dyskinesia, caroli’s disease,
choledochal cyst, clonorchiasis, ascariasis Etc
Secondary—Common 95%—black pigment stones/cholesterol
stones. It is seen in 15% of gallstone disease; 75% are cholesterol
stones, 25% are pigment stones.
Biliary colic because of CBD obstruction by stone-
pain in RHC & epigastrium
Intermittent chills, fever, or jaundice
accompanies biliary colic Charcot’s triad
Suppurative cholangitis Reynold’s pentad
Persistent pain, fever, jaundice, shock & AMS
Painful jaundice with dark color urine, clay
colored stool and pururitus.
Features of Ac Pancreatitis in distal CBD stone
Patient may be icteric and toxic, with high fever and chills, or may
appear to be perfectly healthy.
A palpable gallbladder is unusual in patients with obstructive
jaundice from common duct stone because the obstruction is
transient and partial, and scarring of the gallbladder renders it
inelastic and non distensible.
Courvoisier’s Law: “ In a jaundiced patient if GB is palpably
enlarged it is not due to Gall stone”
Tenderness in the right upper quadrant is not often as marked as in
acute cholecystitis, DU perforation or Ac Pancreatitis
Tender enlarged liver +
Obstructive jaundice due to other causes:
Carcinoma of head of pancreas
Carcinoma of biliary tree- cholangiocarcinoma
Biliary stricture- Scelerosing cholangitis
Intrahepatic cholestasis from drugs, pregnancy, chronic active
hepatitis, or primary biliary cirrhosis may be difficult to distinguish
from extrahepatic obstruction. ERCP would be appropriate to make
Liver dysfunction and biliary
White bile formation and liver
Pancreatitis if CBD stone is near
sphincter of Oddi blocking drainage of
bile and pancreatic duct.
In cholangitis, leukocytosis of 15,000/mL is usual, and values above
20,000/mL are common.
T bilirubin level usually remains under 10 mg/dL, and most are in
the range of 2-4 mg/dL. The direct fraction exceeds the indirect, but
the latter becomes elevated in most cases.
Bilirubin levels do not ordinarily reach the high values seen in
malignant tumors because the obstruction is usually incomplete and
transient. In fact, fluctuating jaundice is so characteristic of
Serum alkaline phosphatase & GGT levels usually rises
Mild increases in AST and ALT are often seen
AXR & USG abdomen- ineffective to pick up CBD stones
USG abdomen may indicate dilated CBD >1cm
CECT- can pick up CBD stone
MRCP- best non-invasive diagnostic investigation
ERCP- Gold standard- diagnostic & therapeutic
EUS- can pick up CBD stone and can take biopsy if there is a mass
In absence of cholangitis:
ERCP, Sphincterotomy, CBD stone removal by dormia basket or
balloon followed by Lap cholecystectomy.
Lap cholecystectomy with Lap CBD exploration
In presence of cholangitis:
ERCP with sphincterotomy and stone extraction or stent placement-
PTBD- Percutaneous transhepatic biliary drainage in ERCP failed
Surgical treatment: Only when above two procedures not possible.
Decompression of CBD with T tube.
Open cholecystectomy, intra op cholangiogram, choledocholithotomy
with T tube placement.
Remove T tube—10 to 14 days after T tube cholangiogram
Missed/retained/residual stones (< 2 years):
If T tube present Percutaneous stone extraction via T tube tract
after 4-6 weeks (Burhenne technique) using choledochoscope
If T tube absent ERCP stone removal
Recurrent stones (> 2 years):
If duct dilated > 2 cm—choledochoduodenostomy or transduodenal