Choledocholithiasis is the presence of at least one gallstone in the common bile duct. The stone may be made up of bile pigments or calcium and cholesterol salts. Gallstones usually form in your gallbladder. The gallbladder is a pear-shaped organ below your liver in the upper-right side of your abdomen. These stones usually remain in the gallbladder or pass through the common bile duct unobstructed. The bile duct is the small tube that carries bile from the gallbladder to the intestine.
According to research published in the Medical Clinics of North America, approximately 15 percent of people who have gallstones develop choledocholithiasis. Of that 15 percent, an estimated five percent to 12 percent have primary bile duct stones.
About 1 in 7 people with gallstones will develop stones in the common bile duct.
Risk factors include a history of gallstones. However, choledocholithiasis can occur in people who have had their gallbladder removed.
Gallstones often pass through the common bile duct unnoticed. However, about 15 percent of all people with gallstones will have gallstones in the bile duct.
There are two types of gallstones: cholesterol stones and pigment stones.
Scientists believe that cholesterol stones are caused by bile that contains:
- Too much cholesterol
- Too much bilirubin
- Not enough bile salts
- They may also occur if the gallbladder does not empty completely or often enough.
The cause of pigment stones is not known. They seem to occur in people who have:
- Cirrhosis of the liver
- Biliary tract infections
- Hereditary blood disorders in which the liver makes too much bilirubin
Often, there are no symptoms unless the stone blocks the common bile duct. Symptoms may include:
- Pain in the right upper or middle upper abdomen for at least 30 minutes. The pain may be constant or cramping. It can feel sharp or dull.
- Yellowing of skin and whites of the eyes (jaundice)
- Loss of appetite
- Nausea and vomiting
- Clay-colored stools
Physical examination — On physical examination, patients with choledocholithiasis often have right upper quadrant or epigastric tenderness. Patients may also appear jaundiced. Courvoisier’s sign (a palpable gallbladder on physical examination) may be seen when gallbladder dilation develops because of an obstruction of the common bile duct. It is more often associated with malignant common bile duct obstruction, but has been reported with choledocholithiasis
Diagnosis and investigations
- Abdominal CT scan
- Abdominal ultrasound
- Endoscopic retrograde cholangiography (ERCP)
- Endoscopic ultrasound
- Magnetic resonance cholangiopancreatography (MRCP)
- Labs: Bilirubin
- Complete blood count (CBC)
- Liver function tests
- Pancreatic enzymes
Who is at Risk for Choledocholithiasis?
People with a history of gallstones or gallbladder disease are at risk for bile duct stones. Even people who have had their gallbladders removed can experience this condition.
Some of the risk factors for gallstones can be improved through lifestyle changes. The following increase your chances of developing gallstones:
- Low-fiber, high-calorie, high-fat diet
- Prolonged fasting
- Rapid weight loss
- Lack of physical activity
Risk factors you cannot change include:
- Age: older adults typically have a higher risk for gallstones
- Gender: women are more likely to have gallstones
- Ethnicity: American Indians and Mexican-Americans are at higher risk for gallstones. Gallstones in the bile duct are more common in Asian populations
- Family history: genetics may play a role
- Gallstones in the bile duct may not cause symptoms for months or even years. However, if the blockage becomes severe, you may experience the following:
- Abdominal pain in the upper or middle-upper abdomen
- Jaundice (yellowing of the skin and eyes)
- Loss of appetite
- Nausea and vomiting
When a gallstone is stuck in the bile duct, the bile can become infected. The bacteria from the infection can spread rapidly. It can move into the ductal system and then into the liver. It can become a life-threatening infection.
The pain caused by gallstones in the bile duct can be sporadic, or it can linger. The pain may also be mild at times and then suddenly severe. Severe pain may require emergency medical treatment. (The most severe symptoms are commonly confused with a cardiac event.)
The goal of treatment is to relieve the blockage.
Treatment may involve:
- Surgery to remove the gallbladder and stones
- ERCP and a procedure called a sphincterotomy, which makes a surgical cut into the muscle in the common bile duct to allow stones to pass or be removed
- Stone extraction
- Fragmenting stones (lithotripsy)
- Surgery to remove the gallbladder and stones (cholecystectomy)
- Surgery that makes a cut into the common bile duct to remove stones or help them pass (sphincterotomy)
- Biliary stenting
- The most common treatment for gallstones in the bile duct is biliary endoscopic sphincterotomy (BES). During a BES procedure, a balloon- or basket-type device is inserted into the bile duct and used to extract the stone or stones. About 85 percent of bile duct stones can be removed with BES.
If a stone does not pass on its own or cannot be removed with BES, doctors may use lithotripsy. This procedure is designed to fragment stones so they can be captured or passed easily.
Patients with gallstones in the bile duct and gallstones still in the gallbladder may be treated with cholecystectomy (gallbladder removal). While performing the surgery, your doctor will also inspect your bile duct to check for remaining gallstones.
If stones cannot be removed completely or you have a history of gallstones causing problems but do not wish to have your gallbladder removed, your doctor may place biliary stents (tiny tubes to open the passage). These will provide adequate drainage and help prevent future choledocholithiasis episodes. The stents can also prevent biliary sepsis (inflammation) and infection.
Blockage and infection caused by stones in the biliary tract can be life threatening. Most of the time, the outcome is good if the problem is detected and treated early.
Complications may include:
- Biliary cirrhosis
Please seek medical attention immediately if any of the following are witnessed
- You develop abdominal pain, with or without fever, and there is no known cause.
- You develop jaundice.
- You have other symptoms of choledocholithiasis.
- Alternative Names
- Gallstone in the bile duct; Bile duct stone
By Srinivas Seela, M.D.