Abstract
Bile duct stones (BDS) are usually secondary to gallstones but may be found primarily in biliary system, although the percentage is minimal. They are usually suspected on history and clinical examination alone but symptoms may be variable ranging from asymptomatic to complications such as biliary colic, pancreatitis, jaundice or cholangitis, the latter can be life-threatening in some patients. Abnormalities in the liver function tests especially the elevated direct bilirubin and alkaline phosphatase indirectly raise the suspicion. The majority of BDS can be diagnosed by Transabdominal Ultrasound, but in some cases further imaging such as, Computed Tomography, Endoscopic Ultrasound or Magnetic Resonance Cholangiography are employed prior to endoscopic or laparoscopic removal. Approximately 90% of BDS can be removed following Endoscopic Retrograde Cholangiography (ERC) + sphincterotomy. Most of the remaining stones can be removed using mechanical lithotripsy. Patients with uncorrected coagulopathies may be treated with ERC + pneumatic dilatation of the sphincter of Oddi. Shockwave lithotripsy (intraductal and extracorporeal) and laser lithotripsy have also been used to fragment large bile duct stones prior to endoscopic removal. Despite all the minimally invasive procedures the role of open surgery for the removal of difficult or impacted stones cannot be completely forgotten. The role of medical therapy in treatment of BDS is currently uncertain. This review focuses on the clinical presentation, investigation and current management of BDS.
Highlights
Stones present in the common bile duct (CBDs) are termed choledocholithiasis
It is replacing endoscopic retrograde cholangiopancreatography (ERCP) for assessing CBD stones leading to biliary obstruction [26]
ERCP is the method of choice in cases of low biliary obstruction, whereas Percutaneous Transhepatic Cholangiography (PTC) is preferred in cases where obstruction is higher than the common hepatic duct, or in case ERCP has failed [35]
Summary
Stones present in the common bile duct (CBDs) are termed choledocholithiasis. The incidence of choledocholithiasis is not known in gallbladder disease [1] but CBD stone develops in about 10-20% of patients with gallstones. CBD stones are found in almost 3-10% of routine cholecystectomy They can present with high bilirubin and raised liver enzymes especially alkaline phosphatase but may be asymptomatic. Intraoperative cholangiography (IOC) during surgery can be utilised to diagnose CBD stones [2]. Modalities to treat these stones include endoscopic retrograde cholangiopancreatography (ERCP) either before or after the surgery, laparoscopic removal or open surgery [3]. Certain factors can influence the clinical practice including status of the disease like patient demographics, most importantly availability of expertise in endoscopic, radiological and surgical procedures, as well as healthcare finances [2]
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