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Choledocholithiasis (Common Bile Duct Stones)

What Causes Choledocholithiasis?

Bile is made by the liver to help with digestion and waste removal. It is stored in the gallbladder. Sometimes, if there is too much of one substance, like cholesterol, in bile, it gets thicker and hardens. This is called a gallstone.

Gallstones can be microscopic or as big as a golf ball. When you have one or more gallstones, it is called cholelithiasis.

Gallstones either stay in the gallbladder or travel with bile through the common bile duct to the small intestine. Choledocholithiasis happens when one or more gallstones get stuck in the common bile duct. Other causes of choledocholithiasis include:

• Genetic predisposition (runs in the family) of high cholesterol or a history of gallstones
• Bile duct abnormalities, such as a narrowing or leak
• High levels of the hormones estrogen and progesterone

People who are prone to gallstones can also get choledocholithiasis. Risk factors for developing gallstones include:

• Obesity
• Blood disorders such as sickle cell disease
• High-calorie, high-fat, low-fiber diet
• Sedentary lifestyle
• Diabetes or insulin resistance
• Rapid weight loss
• Pregnancy
• Hormone replacement therapy or birth control pills
• History of gastrointestinal conditions, such as Crohn’s disease
• Cirrhosis or infections of the bile ducts

Choledocholithiasis Symptoms

A person with bile duct stones may not have symptoms unless their gallstones cause a blockage or inflammation. In these cases, the gallstones can pass through the bile duct at some point without causing any issues.

The most common symptom of choledocholithiasis is pain in the upper right side of the belly, which can be mild or severe. The pain can be constant or come and go. Other symptoms may include:

• Fever
• Nausea and vomiting
• Loss of appetite
• Jaundice (yellowing of the skin and the whites of the eyes)
• Clay-colored poop
• Dark-colored pee

Choledocholithiasis usually is not a medical emergency, but it should be treated. If the gallstones cause a blockage of the common bile duct (called obstructive choledocholithiasis), this can lead to serious complications and may need urgent treatment. These include infection, cholecystitis (infection in the gallbladder) or cholangitis (infection of the common bile duct).

Choledocholithiasis Diagnosis

There are several tests to check for choledocholithiasis. Doctors may do blood tests to look for an infection and check the function of the liver and pancreas. They may do a complete blood count (CBC) test, a liver function test and a measurement of bilirubin and pancreatic enzymes.

To verify that a gallstone is in the common bile duct, doctors can use various imaging tests. These include:

• Transabdominal ultrasound (TUS): This scan uses sound waves to show the liver, gallbladder, pancreas, spleen and kidneys. Cincinnati Children’s is one of only a few pediatric health systems in the country that offers this.
• Endoscopic ultrasound: In this procedure, a narrow, flexible tube (endoscope) is inserted into the mouth and led down to look at the digestive tract. Sound waves are used to check for stones in the bile duct.

Treatment for Choledocholithiasis

In some choledocholithiasis cases, gallstones pass through the common bile duct on their own, and no treatment is needed. However, if the gallstones get stuck, they can cause infection and pancreatitis.

If a stone is stuck in the bile duct, the most common treatment is endoscopic retrograde cholangiography (ERCP). This is a specialized procedure that uses an endoscope with a video camera and contrast dye to identify stones, blockages and narrowing in the bile ducts. Doctors slide tiny tools through the endoscope to break up and remove the stones. They also may perform a:

• Sphincterotomy: making a small cut to increase the opening of the duct so the stones can pass
• Stricture dilation: stretching or expanding an area where the duct is abnormally narrow
• Stent placement: inserting a small, plastic tube in the duct to make it easier to drain

Another option for choledocholithiasis surgery is laparoscopic common bile duct exploration (LCBDE). Surgeons make small cuts in the belly to directly access the common bile duct and remove stones.

After any surgical procedure, patients typically take antibiotics to prevent infection. Patients who don’t have complications usually can go home within a few days.

A potential complication from choledocholithiasis treatment is bile duct fibrosis. This is caused by the recurrence of stones or from scar tissue that forms from cutting the bile duct. It narrows the duct passageway and can block the bile duct. Another procedure may be needed to treat it.

Doctors typically recommend surgery to remove the gallbladder, called a cholecystectomy. This aims to prevent more gallstones from getting stuck in the common bile duct and causing choledocholithiasis again. People can function well without their gallbladder.

Choledocholithiasis Prognosis

It may not be possible to prevent choledocholithiasis. Gallstones can come back in the common bile ducts within 10 to 20 years of choledocholithiasis treatment.

Removing the gallbladder usually prevents the recurrence of gallstones. Although rare, gallstones can still form within the common bile duct after the gallbladder has been removed. These are called recurrent gallstones. This can lead to choledocholithiasis without a gallbladder.

Whenever possible, children should be treated for choledocholithiasis at a pediatric hospital that has expertise and a multidisciplinary team of specialists.