AM report pearls SFGH 6/30 – choledocholithiasis

Pearls:

    • Most cases of choledocholithiasis in the western world are from passage of gallstones from the gallbladder to the common bile duct (CBD)
    • formation of stones within CBD (primary choledocholithiasis) is less common but can occur in bile stasis (e.g. cystic fibrosis), anatomic abnormalities including dilation with age, recurrent or persistent infection of the biliary system (common in East Asia)
    • MRCP versus endoscopic ultrasound can be used to confirm the diagnosis of choledocholithiasis in patients with high risk of complications from ERCP or intermediate likelihood of stone

Choledocholithiasis: evernote link: http://www.evernote.com/l/AoMzopuM00ZCUZDnFY0eSvvlTyEV6W8J-_0/

  • definition: gallstones within the common bile duct
  • etiology:
    • most from passage of gallstones from gallbladder to common bile duct (CBD)
    • formation of stones within CBD (primary choledocholithiasis) is less common but can occur in bile stasis (e.g. cystic fibrosis), anatomic abnormalities including dilation with age, recurrent or persistent infection of the biliary system (common in East Asia)
  • clinical presentation:
    • uncomplicated:
      • RUQ or epigastric pain, N/V, occasionally asymptomatic
      • courvoisier’s sign (palpable gallbladder) – usually with malignancy, but can occur with CBD obstruction
    • complicated: uncomplicated presentation + can have acute pancreatitis or cholangitis
  • Labs:
    • typically cholestatic LFT abnormalities (elevated bili and alk phos)
    • ALT/AST are typically elevated early on
  • diagnostic approach (2010 gastrointestinal endoscopy guidelines)
    • high likelihood: ERCP
    • intermediate likelihood of stone: consider endoscopic ultrasound or MRCP vs lap chole with intraoperative cholangiography
    • transabdominal ultrasound:73% sensitivity for choledocolithiasis (poor sensitivity for distal CBD b/c oftentimes obscured by bowel gas  – 6 mm cutoff commonly used
    • ERCP: 80-93% sensitivity, 99% specificity – complications including pancreatitis, bleeding, perforation
    • EUS: 94% sensitivity
    • MRCP: 93% sensitivity, 94% specificity
    • no significant difference in accuracy of EUS vs MRCP
    • contrast CT – sensitivity 65-93%, specificity: 84-100%
  • management: removal of the stone (ERCP versus surgically)

Baron and Ferreira. Acute biliary conditions. Best Practice and research clinical gastroenterology. 27(5) 2013:745-756.

Arain et al.  Choledocholithiasis: Clinical manifestations, diagnosis, and management.  Up to date. 5/2015.

Advertisements

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s