Choledocholithiasis: Diagnosis and management
With Dr. Jeff Ponsky · StayCurrentMD
Part of
Choledocholithiasis 5 items
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Patients with deep jaundice or cholangitis (jaundice, fever, right upper quadrant pain, sometimes sepsis) are potential candidates for emergency ERCP to relieve common bile duct obstruction.
Patients with gallstone pancreatitis (jaundice, abdominal pain, and elevated pancreatic enzymes) are potential candidates for emergency ERCP.
If a patient's pancreatitis improves the next day, there is no rush to do the ERCP.
The first thing to do in the management of a patient with suspected common bile duct stones is to get an intraoperative cholangiogram.
Transcystic exploration is amenable to small stones, usually in the distal duct.
You can dilate the cystic duct with a balloon or ureteral dilator and then pass a choledochoscope or basket for transcystic stone removal.
You can flush or push tiny stones through the papilla of Vater using glucagon to relax the papilla.
For laparoscopic common bile duct exploration, you make a small incision (perhaps 1 centimeter) in the anterior surface of the common bile duct.
You can use Fogarty balloons or baskets and eventually choledochoscope, both upward and downward, to clear stones from the common bile duct.
For T-tube placement, you use a 12 or 14 T tube, cut the back wall off, slice it longitudinally, put it into the abdomen and place its arms into the duct both proximally and distally.
Use a dissolvable suture such as Vicryl or chromic to put a stitch one distal to the tube and one proximal to the tube.
After CBD exploration, take out the gallbladder and put a drain in the foramen of Winslow.
A surgeon should consider converting to open CBD exploration when the inflammation is great, when unfamiliar with laparoscopic suturing techniques, or when exposure is not good.
In open technique, you do a Kocher maneuver where you take down the lateral peritoneum lateral to the duodenum so you can put traction on the common duct by holding the duodenum and pancreatic head.
For transduodenal sphincteroplasty when stones are impacted at the papilla, you make a duodenotomy over the papilla, take small clamps and go into the 11 o'clock position and open the papilla a few millimeters at a time, similar to endoscopic sphincterotomy.
Transduodenal sphincteroplasty is not very common anymore.
Essential instruments for CBD exploration include cholangiogram catheters, contrast material, dilating balloons for the cystic duct, balloons and baskets for the common duct, and a choledochoscope.
Many instruments for CBD exploration can be obtained from the urology cart because they use similar items for the ureter and ureteral stones.
The choledochoscope is an inexpensive tool which makes laparoscopic or open common bile duct exploration very easy.
Choledocholithiasis is a disease that belongs to the surgeons, and to use ERCP as an adjunct is appropriate, but the surgeon should be comfortable doing exploration and management of common bile duct stones.
If GGT and alk phos are elevated, you should think obstruction of the common bile duct.
If you see dilation of the common bile duct greater than 7 millimeters on ultrasound, you should think obstruction potentially with stones.
ERCP is definitely overused.
If a patient can go to the operating room and have an intraoperative cholangiogram and management of the common bile duct stones in one episode, they may be better off than having a preoperative ERCP.
If there is any question that there may be remaining stones in the bile duct or distal high pressure at the papilla, a T tube should be used as this will decompress the duct, allow it to heal, and allow access to the duct should there be a retained stone later.
The T tube is removed 10 days to 2 weeks later, even in the office.
If the duct is very dilated, very filled with stones, or if you cannot remove distal stones, consider a drainage procedure (choledochojejunostomy or choledochoduodenostomy) which provides permanent drainage.