Choledocholithiasis & Gallstone Pancreatitis

• • Cholesterol stone risk factors include:

  • -Female gender

    -Age

    -Obesity

    -Estrogen exposure

    -Fatty diet

    -Rapid weight loss

  • Complicated gallstone disease affects < 0.5% annually of patients who are asymptomatic

Epidemiology

• • Average age generally 10 years older than those affected by cholelithiasis (eg, 40-50 years of age)

Symptoms and Signs

• • Right upper quadrant pain

  • Painless jaundice

  • Both pain and jaundice

  • Fever

  • Asymptomatic

  • Nausea

  • Vomiting

  • Anorexia

Laboratory Findings

• • Conjugated hyperbilirubinemia (for choledocholithiasis)

  • Elevated alkaline phosphatase (for choledocholithiasis)

  • Leukocytosis (for pancreatitis or cholangitis)

Imaging Findings

• • Right upper quadrant US showing presence of gallstones, dilated common bile duct (CBD) (> 6 mm) and CBD stone in only 20-30% of patients with choledocholithiasis

  • ERCP showing dilated CBD and presence of single or multiple CBD stones in patients with choledocholithiasis

  • ERCP showing impacted ampullary gallstone in < 10 % of patients with gallstone pancreatitis

• • Presence of signs or symptoms suggestive of cholangitis

Rule Out

• • Biliary stricture

• • History and physical exam

  • CBC

  • Liver function tests

  • Amylase and lipase

  • Right upper quadrant US

  • ERCP or laparoscopic cholangiogram

Surgery

• • ERCP with sphincterotomy and stone extraction followed by laparoscopic cholecystectomy (preferred when cholangitis present or if pancreatitis does not resolve)

  • Laparoscopic cholecystectomy with CBD exploration

  • Laparoscopic cholecystectomy and cholangiogram followed by ERCP and stone extraction (preferred stone extraction technique is center specific for stones noted on screening cholangiogram following resolution of gallstone pancreatitis)

  • Percutaneous transhepatic cholangiography and stone extraction if ERCP unsuccessful and cholangitis present

Indications

• • Choledocholithiasis noted to be symptomatic or asymptomatic

  • Gallstone pancreatitis

Medications

• • Antibiotics to cover GI flora for cases of cholangitis

Complications

• • Pancreatitis (for ERCP)

  • Bile duct injury or leak

Prognosis

• • Gallstone pancreatitis resolves in > 90% of cases

Prevention

• • Treatment of symptomatic cholelithiasis

References