Choledocholithiasis is the presence of
gallstoneIn medicine, gallstones are crystalline bodies formed within the body by accretion or concretion of normal or abnormal bile components.Gallstones can occur anywhere within the biliary tree, including the gallbladder and the common bile duct...
s in the
common bile ductThe common bile duct is a tube-like anatomic structure in the human gastrointestinal tract. It is formed by the union of the common hepatic duct and the cystic duct . It is later joined by the pancreatic duct to form the ampulla of Vater...
. This condition causes
jaundiceJaundice, also known as icterus , is a yellowish discoloration of the skin, the conjunctival membranes over the sclerae , and other mucous membranes caused by hyperbilirubinemia...
and
liverThe liver is a vital organ present in vertebrates and some other animals; it has a wide range of functions, including detoxification, protein synthesis, and production of biochemicals necessary for digestion...
cell damage, and is a
medical emergencyA medical emergency is an injury or illness that is acute and poses an immediate risk to a person's life or long term health. These emergencies may require assistance from another person, who should ideally be suitably qualified to do so, although some of these emergencies can be dealt with by the...
, requiring the endoscopic retrograde cholangiopancreatography (ERCP) procedure or
surgicalCholecystectomy is the surgical removal of the gallbladder. Despite the development of non-surgical techniques, it is the most common method for treating symptomatic gallstones, although there are other indications for the procedure, including carcinoma...
treatment.
A tendency for this disease can be inherited.
While stones can frequently pass through the common bile duct into the
duodenumThe duodenum is the first section of the small intestine in most higher vertebrates, including mammals, reptiles, and birds. In fish, the divisions of the small intestine are not as clear and the terms anterior intestine or proximal intestine may be used instead of duodenum...
, some stones may be too large to pass through the CBD and may cause an obstruction.
Choledocholithiasis is the presence of
gallstoneIn medicine, gallstones are crystalline bodies formed within the body by accretion or concretion of normal or abnormal bile components.Gallstones can occur anywhere within the biliary tree, including the gallbladder and the common bile duct...
s in the
common bile ductThe common bile duct is a tube-like anatomic structure in the human gastrointestinal tract. It is formed by the union of the common hepatic duct and the cystic duct . It is later joined by the pancreatic duct to form the ampulla of Vater...
. This condition causes
jaundiceJaundice, also known as icterus , is a yellowish discoloration of the skin, the conjunctival membranes over the sclerae , and other mucous membranes caused by hyperbilirubinemia...
and
liverThe liver is a vital organ present in vertebrates and some other animals; it has a wide range of functions, including detoxification, protein synthesis, and production of biochemicals necessary for digestion...
cell damage, and is a
medical emergencyA medical emergency is an injury or illness that is acute and poses an immediate risk to a person's life or long term health. These emergencies may require assistance from another person, who should ideally be suitably qualified to do so, although some of these emergencies can be dealt with by the...
, requiring the endoscopic retrograde cholangiopancreatography (ERCP) procedure or
surgicalCholecystectomy is the surgical removal of the gallbladder. Despite the development of non-surgical techniques, it is the most common method for treating symptomatic gallstones, although there are other indications for the procedure, including carcinoma...
treatment.
A tendency for this disease can be inherited.
Cause
While stones can frequently pass through the common bile duct into the
duodenumThe duodenum is the first section of the small intestine in most higher vertebrates, including mammals, reptiles, and birds. In fish, the divisions of the small intestine are not as clear and the terms anterior intestine or proximal intestine may be used instead of duodenum...
, some stones may be too large to pass through the CBD and may cause an obstruction. One risk factor for this is duodenal
diverticulumA diverticulum is medical or biological term for an outpouching of a hollow structure in the body.In medicine the term usually implies that the structure is not normally present, i.e., pathological...
.
Complications
This obstruction leads to jaundice, elevation in
alkaline phosphataseAlkaline phosphatase is a hydrolase enzyme responsible for removing phosphate groups from many types of molecules, including nucleotides, proteins, and alkaloids. The process of removing the phosphate group is called dephosphorylation. As the name suggests, alkaline phosphatases are most...
, increase in conjugated
bilirubinBilirubin is the yellow breakdown product of normal heme catabolism. Heme is found in hemoglobin, a principal component of red blood cells. Bilirubin is excreted in bile, and its levels are elevated in certain diseases...
in the blood and increase in
cholesterolCholesterol is a lipidic, waxy steroid found in the cell membranes and transported in the blood plasma of all animals. It is an essential component of mammalian cell membranes, where it is required to establish proper membrane permeability and fluidity...
in the blood. It can also cause acute
pancreatitisPancreatitis is inflammation of the pancreas that can occur in two very different forms. Acute pancreatitis is sudden while chronic pancreatitis "is characterized by recurring or persistent abdominal pain with or without steatorrhea or diabetes mellitus."...
and
ascending cholangitisAscending cholangitis or acute cholangitis is an infection of the bile duct , usually caused by bacteria ascending from its junction with the duodenum...
.
Diagnosis
Choledocholithiasis (stones in common bile duct) is one of the complications of cholelithiasis (gallstones), so the initial step is to confirm the diagnosis of cholelithiasis. Typically patients with cholelithiasis present with pain in the right upper quadrant of the abdomen with the associated symptoms of nausea and vomiting, especially after a fatty meal. The physician can confirm the diagnosis of cholelithiasis with an abdominal ultrasound that shows the ultrasonic shadows of the stones in the gallbladder.
The diagnosis of choledocholithiasis is suggested when the liver function blood test shows an elevation in bilirubin. The diagnosis is confirmed either with an MRCP, ERCP, or an intraoperative cholangiogram. If the patient must have the gallbladder removed for gallstones, the surgeon may choose proceed with the surgery, and obtain a cholangiogram during the surgery. If the cholangiogram shows stone in the bile duct, the surgeon may attempt to treat the problem by flushing the stone into the intestine or retrieve the stone back through the cystic duct.
On a different pathway, the physician may choose to proceed with ERCP before surgery. The benefit of ERCP is that it can be utilized not just to diagnose, but also to treat the problem. During ERCP the endoscopist may surgically widen the opening into the bile duct and remove the stone through that opening. ERCP, however, is an invasive procedure and has its own potential complication. Thus, if the suspicion is low, the physician may choose to confirm the diagnosis with MRCP, a non-invasive imaging, before proceeding with ERCP or surgery.
Treatment
Treatment involves removing the stone using ERCP. Typically, the gallbladder is then removed, an operation called
cholecystectomyCholecystectomy is the surgical removal of the gallbladder. Despite the development of non-surgical techniques, it is the most common method for treating symptomatic gallstones, although there are other indications for the procedure, including carcinoma...
, to prevent a future occurrence of common bile duct obstruction.