Choledocholithiasis involves stones in the common bile duct, occurring in 10-15% of gallstone patients, predominantly as secondary stones that migrate from the gallbladder. Clinical features can include abdominal pain, jaundice, and symptoms may vary from asymptomatic to acute conditions. Diagnosis typically involves ERCP as the gold standard, with treatment options including ERCP with sphincterotomy and laparoscopic choledocholithotomy in select cases.

1. Choledocholithiasis
Ghadeer Ismail Eideh
Supervised by Dr. Aref Rajabi
From: step up to medicine

2. Outlines
Introduction
01 02 Clinical features
03 Diagnosis
04 Treatment

3. INTRODUCTION
choledocholithiasis
Stones in the common bile duct,
occur in 10–15% of patients with
gallstones, which have usually
migrated from the gallbladder.

6. Primary VS secondary stones

7. • Primary stones originate in the CBD (usually
pigmented stones).
• They are rare but can develop within the
common bile duct many years after a
cholecystectomy, and are sometimes related
to biliary sludge arising from dysfunction of
the sphincter of Oddi.
• In Far Eastern countries, are thought to follow
bacterial infection secondary to parasitic
infections with Clonorchis sinensis, Ascaris
lumbricoides or Fasciola hepatica
Primary stones
Secondary stones originate in the
gallbladder and then pass into the
CBD (usually cholesterol or mixed
stones). These account for 95% of
all cases.
Secondary stones

8. Clinical features

9. Choledocholithiasis may be
asymptomatic, may be
found incidentally by
operative cholangiography
at cholecystectomy, or may
manifest as recurrent
abdominal pain with or
without jaundice.
Clinical features
The pain is usually in the
right upper quadrant, and
fever, pruritus and dark
urine may be present.
Physical examination
may show the scar of a
previous
cholecystectomy; if the
gallbladder is present, it
is usually small, fibrotic
and impalpable.

10. Diagnosis

11. Diagnosis
Laboratory tests
ERCP
RUQ ultrasound
ERCP
Is the gold standard (sensitivity and
specificity of 95%) and should
follow ultrasound. ERCP is
diagnostic and therapeutic
Lab-test
Total and direct bilirubin
levels are elevated, as well
as ALK-P.
PTC is an
alternative to ERCP
RUQ ultrasound
Is usually the initial study, but is not a
sensitive study for choledocholithiasis.
It detects CBD in only 50% of cases.

12. transabdominal ultrasound
● This shows dilated extrahepatic and
intrahepatic bile ducts, together with
gallbladder stones (Fig. 22.46), but does not
always reveal the cause of the obstruction in
the common bile duct; 50% of bile duct stones
are missed , particularly those in the distal
common bile duct.
● EUS is extremely accurate at identifying bile
duct stones.
● MRCP is non-invasive and is indicated when
intervention is not necessarily mandatory (e.g.
the patient with possible bile duct stones but no
jaundice or sepsis).

13. Complications

14. Complications of choledocholithiasis
Biliary colic Biliary cirrhosis
Cholangitis Obstructive
jaundice
Acute
pancreatitis

15. Cholelithiasis Versus
Choledocholithiasis

17. Treatment

18. Treatment
01
ERCP with sphincterotomy and
stone extraction with stent
placement (successful in 90% of
patients).
02
Laparoscopic choledocholithotomy
(in select cases)

19. Thank you