Choledocholithiasis occurs when a gallstone blocks the common bile duct and bile cannot flow past it, instead backing up into the liver.
The gallbladder is a pouch the size of a lime that sits under the liver and stores bile. Bile is produced by the liver and helps with digestion of fat. Sometimes the cholesterol in bile can deposit and form thick crystals (sludge) or stones (gallstones). These stones can get stuck in the gallbladder, in the duct that goes from the gallbladder to the large bile duct (cystic duct), or in the large duct that goes from the liver and gallbladder to the bowel (common bile duct).
Patients often have right-sided abdominal pain and may have yellowing of the skin or eyes (jaundice). Patients may also experience clay-colored stools and dark urine. If the stone is stuck in the common bile duct in such a way that the enzymes from the pancreas also cannot flow to the small intestine, it can lead to gallstone pancreatitis, which can cause right, middle, and left upper abdominal pain; nausea; and vomiting. If the gallbladder becomes inflamed, it can lead to acute cholecystitis. If there is an infection of the ducts through which the bile flows, it leads to cholangitis. Both of these can cause right-sided abdominal pain, nausea, vomiting, and fever.
The diagnosis is made by performing a patient history, physical examination, blood tests, and imaging of the abdomen (ultrasound and magnetic resonance imaging).
Treatment depends on the location of the blockage and what problems develop because of it.
Choledocholithiasis requires a gastroenterologist to extract the stone. This is usually done with heavy sedation, not general anesthesia. A long tube (endoscope) with a camera is introduced through the mouth, esophagus, stomach, and into the small bowel. The point where the bile duct opens into the small bowel is then identified and the stone is pulled out. This procedure is called endoscopic retrograde cholangiopancreatography.
Gallstone pancreatitis is usually treated with hydration through intravenous fluids and pain medication.
Acute cholecystitis is treated with antibiotics and surgery.
Cholangitis is treated with antibiotics and removal of the stone caught in the duct.
All of these conditions require surgical removal of the gallbladder to prevent future attacks.
A blocked stone usually causes pain, nausea, and vomiting. Lack of pain in the presence of jaundice and abnormal liver tests should raise concern for other disease processes such as hepatitis or, less frequently, bile duct or pancreatic cancer.
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A JAMA Patient Page on laparoscopic cholecystectomy was published in the May 1, 2018, issue of JAMA. To find this and other JAMA Patient Pages, go to the For Patients collection at jamanetworkpatientpages.com.
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Source: Wandling MW, Hungness ES, Pavey ES, et al. Nationwide assessment of trends in choledocholithiasis management in the United States from 1998 to 2013. JAMA Surg. 2016;151(12):1125-1130.