Choledocholethiasis, or bile duct stones, refers to the presence of stones in bile duct. These stones usually form in the gall bladder and then migrate to the bile duct.
Presentation
In most of the cases, the patient remains asymptomatic with the stones passing to the duodenum or even when remaining within the duct. When the stones obstruct the duct, a number of clinical manifestations results. Colicky pain in the upper right quadrant, particularly after cholecystectomy, is the most common symptom of choledochothiasis. The pain may be sporadic and may spread to the right scapular tip [6]. The pain usually commences within 5 to 60 min after a fatty meal. The dull, intense pain may increase for few minutes and then reduce gradually. If the disease progresses to cholangitis, fever, chills, jaundice and increased serum levels of alkaline phosphatase and transaminases ensue. Ascending cholangitis may also lead to sepsis, requiring immediate drainage of bile duct and antibiotic treatment. Tachycardia and hypotension are also common among patients with ascending cholangitis.
Entire Body System
- Fever
Fever Yellowing of skin and whites of the eyes (jaundice) Loss of appetite Nausea and vomiting Clay-colored stools The goal of treatment is to relieve the blockage. [nlm.nih.gov]
Fever. Yellowing of skin and whites of the eyes (jaundice). Loss of appetite. Nausea and vomiting. Clay-colored stools. [ufhealth.org]
Fever and rigors may be present if there is an associated ascending cholangitis. Patients with symptoms or signs suggestive of bacterial cholangitis (fever or shaking chills in addition to cholestasis) should be hospitalized. [hepatitis.va.gov]
By comparing them, was observed that fever and jaundice were the signs and symptoms with statistical significance. [ncbi.nlm.nih.gov]
Usually have abnormalities in liver enzymes and pain but no fever. The 2 major complications are 1) Cholangitis and 2) Acute pancreatitis. [sketchymedicine.com]
- Weight Loss
Risk factors for choledolithiasis include female gender, obesity, pregnancy, medication and weight loss. There have been multiple cases of choledocholithiasis associated with weight loss from bariatric surgery. [pediatrics.aappublications.org]
General Prevention Maintain healthy weight and lifestyle. Avoid rapid weight loss. Consider UDCA therapy in LPAC syndrome. [unboundmedicine.com]
In our post-bariatric group, the 33 patients who developed symptomatic stones had percentage total weight loss of 30.99 + 4.1 (P CONCLUSIONS: We recommend routine synchronous cholecystectomy with bariatric procedure. [ncbi.nlm.nih.gov]
Mental status changes Asymptomatic, weight loss, jaundice, or abdominal pain Related to cause. [clinicaladvisor.com]
Features of MyAccess include: Remote Access Favorites Save figures into PowerPoint Download tables as PDFs Go to My Dashboard Close • Cholesterol stone risk factors include: -Female gender -Age -Obesity -Estrogen exposure -Fatty diet -Rapid weight loss [accesssurgery.mhmedical.com]
- Inflammation
Gallbladder cancer Chronic gallbladder inflammation increases the risk of gallbladder carcinoma! [amboss.com]
The pain is entirely visceral and generally lasts Cholecystitis – inflammation of the GB. It’s biliary colic that just doesn’t go away. [sketchymedicine.com]
Parasitic infestation can cause obstructive jaundice with intrahepatic ductal inflammation, proximal stasis, stone formation, and cholangitis. [merckmanuals.com]
Biliary narrowing and swelling of the tissue around the stone can cause irritation and inflammation of the bile duct. Up the biliary tree. Inflammation can progress up the biliary tree and cause infection of any of the bile ducts. [nurseslabs.com]
- Chills
[…] kō-led'ō-kō-lith-ī'ă-sis), Presence of a stone in the common bile duct. choledocholithiasis Common bile duct stone(s) GI disease The presence of gallstones in the common bile duct, which occurs in ±15% of Pts with gallstones Clinical Abdominal pain, N&V; if severe, fever, chills [medical-dictionary.thefreedictionary.com]
Patients with symptoms or signs suggestive of bacterial cholangitis (fever or shaking chills in addition to cholestasis) should be hospitalized. [hepatitis.va.gov]
[…] an ED visit with reported subjective fever; exam, however, was not consistent with cholangitis Recall that cholangitis is one of the most dangerous complications of CBD stones Acute cholangitis involves biliary pain, jaundice, and spiking fevers with chills [errolozdalga.com]
Clinical Features Patient may be icteric and toxic, with high fever and chills, or may appear to be perfectly healthy. [slideshare.net]
- Anorexia
She had been developing signs and symptoms consistent with anorexia nervosa for six months preceding her admission. [pediatrics.aappublications.org]
[…] patients who are asymptomatic • Average age generally 10 years older than those affected by cholelithiasis (eg, 40-50 years of age) • Right upper quadrant pain • Painless jaundice • Both pain and jaundice • Fever • Asymptomatic • Nausea • Vomiting • Anorexia [accesssurgery.mhmedical.com]
Chronic cholecystitis Anorexia, flatulence, nausea, fat intolerance; episodic or diffuse abdominal pain, heartburn. Choledolithiasis Asymptomatic, or jaundice and pain. [medi-info.com]
[…] jaundice (scleral icterus, dark urine, acholic stool), cholangitis (fever, abdominal pain, jaundice, hypotension, mental status changes), and pancreatitis (constant epigastric pain radiating to the back, nausea, vomiting, anorexia). [clinicaladvisor.com]
Respiratoric
- Pneumonia
DDx Biliary leaks Liver abscess Infected choledochal cysts Cholecystitis Mirizzi syndrome Right lower lobe pneumonia/empyema Lab values Biliary Colic Cholecystitis Choledocholithiasis Cholangitis Gallbladder Pancreatitis WBC – ↑ ↑ ↑↑ ↑ AST – – ↑ ↑ ↑ ALT [sketchymedicine.com]
Gallbladder disease Acute cholecystitis Cholangitis Symptomatic cholelithiasis/Biliary Colic Acalculous cholecystitis Gallstone pancreatitis Choledocholithiasis Peptic ulcer disease with or without perforation Pancreatitis Acute hepatitis Pyelonephritis Pneumonia [wikem.org]
CONCLUSION: E. coli, K. pneumoniae, E. faecalis and Streptoccocus sp. were the most common bacteria isolated in the bile of patients with cholangitis and choledocholithiasis, which were sensitive to a simple therapeutic regimen, such as the combination [wikigenes.org]
These may include: Problems with anesthesia Infection Bleeding Swelling Bile leakage Damage to a bile duct Damage to your intestine, bowel, or blood vessels Deep vein thrombosis ( blood clots ) Heart problems Pneumonia You also run the risk of a problem [m.webmd.com]
The plasmid of Chlamydia trachomatis and Chlamydophila pneumoniae (N16): accurate determination of copy number and the paradoxical effect of plasmid-curing agents. Microbiology. 2005; 151(3): 893-903. [aig-journal.ru]
Gastrointestinal
- Abdominal Pain
OBJECTIVES: Although abdominal pain is a cardinal feature of choledocholithiasis, there has been little formal study of the features of pain in this condition. [ncbi.nlm.nih.gov]
Patients often have right-sided abdominal pain and may have yellowing of the skin or eyes (jaundice). Patients may also experience clay-colored stools and dark urine. [jamanetwork.com]
Call your provider if: You develop abdominal pain, with or without fever, and there is no known cause. You develop jaundice. You have other symptoms of choledocholithiasis. Gallstone in the bile duct; Bile duct stone Fogel EL, Sherman S. [nlm.nih.gov]
Mental status changes Asymptomatic, weight loss, jaundice, or abdominal pain Related to cause. [clinicaladvisor.com]
- Vomiting
Both of these can cause right-sided abdominal pain, nausea, vomiting, and fever. The diagnosis is made by performing a patient history, physical examination, blood tests, and imaging of the abdomen (ultrasound and magnetic resonance imaging). [jamanetwork.com]
Fever Yellowing of skin and whites of the eyes (jaundice) Loss of appetite Nausea and vomiting Clay-colored stools The goal of treatment is to relieve the blockage. [nlm.nih.gov]
She had vomiting at 157 days of age. Ultrasonography revealed calculi in the gallbladder and a dilated common bile duct. [ncbi.nlm.nih.gov]
Nausea and vomiting. Clay-colored stools. [ufhealth.org]
- Nausea
Associated symptoms of nausea (69.2%) and vomiting (30.7%) were common. No differences in pain characteristics were detected between those with or without a prior cholecystectomy. [ncbi.nlm.nih.gov]
Both of these can cause right-sided abdominal pain, nausea, vomiting, and fever. The diagnosis is made by performing a patient history, physical examination, blood tests, and imaging of the abdomen (ultrasound and magnetic resonance imaging). [jamanetwork.com]
Fever Yellowing of skin and whites of the eyes (jaundice) Loss of appetite Nausea and vomiting Clay-colored stools The goal of treatment is to relieve the blockage. [nlm.nih.gov]
Acute cholecystitis Colicky pain in right upper quadrant and right lower scapula; nausea, vomiting; low-grade fever. Chronic cholecystitis Anorexia, flatulence, nausea, fat intolerance; episodic or diffuse abdominal pain, heartburn. [medi-info.com]
Nausea and vomiting. Clay-colored stools. [ufhealth.org]
- Clay-Colored Stool
Fever Yellowing of skin and whites of the eyes (jaundice) Loss of appetite Nausea and vomiting Clay-colored stools The goal of treatment is to relieve the blockage. [nlm.nih.gov]
Fever Yellowing of skin and whites of the eyes (jaundice) Loss of appetite Nausea and vomiting Clay-colored stools Exams and Tests Tests that show the location of stones in the bile duct include the following: Abdominal CT scan Abdominal ultrasound Endoscopic [mountsinai.org]
Clay-colored stools. The goal of treatment is to relieve the blockage. [medlineplus.gov]
Fever Yellowing of skin and whites of the eyes (jaundice) Loss of appetite Nausea and vomiting Clay-colored stools Treatment The goal of treatment is to relieve the blockage. [account.allinahealth.org]
- Epigastric Pain
A 10-year-old girl visited our hospital because of right epigastric pain and fever. Cholelithiasis and choledocholithiasis were diagnosed by ultrasound examination. [ncbi.nlm.nih.gov]
Case An 88-year-old man presented to the emergency department with acute epigastric pain and vomiting. On physical examination, his blood pressure was 79/39 mm Hg and he had right upper quadrant tenderness. [academic.oup.com]
Cardiovascular
- Chest Pain
There was no fever, back pain, altered mental status, or chest pain. His past medical history was significant for a heterozygous in‐frame mutation of Hemoglobin Evans [alpha2 62(E11) Val→Met]. [ncbi.nlm.nih.gov]
[…] for chest pain, regardless of internal injuries liver depression, trauma or flutter can be applied, for better compatibility Cyperus effect. [0013] 桅子:味苦。 [patents.google.com]
Liver, Gall & Pancreas
- Jaundice
Fever Yellowing of skin and whites of the eyes (jaundice) Loss of appetite Nausea and vomiting Clay-colored stools The goal of treatment is to relieve the blockage. [nlm.nih.gov]
Obstructive Jaundice) Progression of Common Bile Duct Stone (Choledocholithiasis, Cholangitis, Obstructive Jaundice) Symptoms of Common Bile Duct Stone (Choledocholithiasis, Cholangitis, Obstructive Jaundice) Clinical Examination of Common Bile Duct [healthengine.com.au]
Yellowing of skin and whites of the eyes (jaundice). Loss of appetite. Nausea and vomiting. Clay-colored stools. [ufhealth.org]
- Biliary Colic
DDx Biliary leaks Liver abscess Infected choledochal cysts Cholecystitis Mirizzi syndrome Right lower lobe pneumonia/empyema Lab values Biliary Colic Cholecystitis Choledocholithiasis Cholangitis Gallbladder Pancreatitis WBC – ↑ ↑ ↑↑ ↑ AST – – ↑ ↑ ↑ ALT [sketchymedicine.com]
Stones within the bile ducts are often asymptomatic and may be found incidentally, however, more frequently they lead to symptomatic presentation with: biliary colic ascending cholangitis obstructive jaundice acute pancreatitis Stones within the bile [radiopaedia.org]
Gallbladder disease types Acute calculous cholecystitis Cholangitis (ascending cholangitis) Symptomatic cholelithiasis (biliary colic) Acalculous cholecystitis Choledocholithiasis Clinical Features RUQ pain Radiation to the right shoulder (phrenic nerve [wikem.org]
These stones cause biliary colic, biliary obstruction, gallstone pancreatitis, or cholangitis (bile duct infection and inflammation). Cholangitis, in turn, can lead to strictures, stasis, and choledocholithiasis. [msdmanuals.com]
- Murphy's Sign
Symptoms During physical examination, Murphy’s sign is usually negative, which helps to distinguish choledocholithiasis from cholecystitis. [ahealthgroup.com]
In addition to the Murphy sign (inspiratory arrest during RUQ palpation due to pain), typical signs include fever and RUQ guarding. The diagnosis is made clinically and confirmed via ultrasound. [amboss.com]
Signs and symptoms [ edit ] Murphy's sign is commonly negative on physical examination in choledocholithiasis, helping to distinguish it from cholecystitis. Jaundice of the skin or eyes is an important physical finding in biliary obstruction. [en.wikipedia.org]
Physical exam reveals tenderness to palpation in the right upper quadrant and negative Murphy sign. Laboratory results show increased alkaline phosphatase and total bilirubin. [step2.medbullets.com]
- Scleral Icterus
Scleral icterus may be present, but is not a reliable sign. In case of cholangitis, fever, tachycardia and hypotension may be present. [hepatitis.va.gov]
icterus Caused by buildup of direct bilirubin in blood Differential Diagnosis RUQ Pain Gallbladder disease Acute cholecystitis Cholangitis Symptomatic cholelithiasis/Biliary Colic Acalculous cholecystitis Gallstone pancreatitis Choledocholithiasis Peptic [wikem.org]
She has slight scleral icterus. She has noted dark- coloured urine. The remainder of her abdominal exam is negative. Vitals: BP-90/60 mms of Hg; PR-110/mt; RR-16/mt;T:102*F 5. [slideshare.net]
[…] constellation of clinical Choledocholithiasis can present with five constellations of clinical features: asymptomatic, biliary colic (episodic but constant right upper quadrant or epigastric abdominal pain, nausea, vomiting, anorexia), obstructive jaundice (scleral [clinicaladvisor.com]
Note should be made for any hyperthermia, diaphoresis, jaundice, scleral icterus, tachycardia, hypotension, tachypnea, or right upper quadrant abdominal tenderness. [ncbi.nlm.nih.gov]
- Hepatomegaly
[…] cholecystitis Gallstone pancreatitis Choledocholithiasis Peptic ulcer disease with or without perforation Pancreatitis Acute hepatitis Pyelonephritis Pneumonia Kidney stone GERD Appendicitis (retrocecal) Pyogenic liver abscess Fitz-Hugh-Curtis Syndrome Hepatomegaly [wikem.org]
His abdomen was soft and lax, mildly distended with hepatomegaly about 4 cm below the costal margin, round edge, firm, not tender with a span of 8.5 cm, with no other significant findings on examinations. [saudisurgj.org]
Skin
- Pruritus
A 57-year-old Japanese man who had undergone LC 6 years previously was referred to our hospital with pruritus and jaundice. [ncbi.nlm.nih.gov]
진단 1) 혈청 빌리루빈, ALP 증가 2) 초음파 검사, MRC(magnetic resonance cholangiography) 3) Endoscopic cholangiography(gold standard) : CBD stone 여부 및 위치 확인, 치료도 가능 → 총수담관담석증(Choledocholithiasis, CBD stone, 온쓸개관돌증) 증상 : Obstructive jaundice ① Jaundice, pruritus, dark [m.blog.naver.com]
Jaundice with or without cholestatic features like pruritus and clay colored stools, fever with chills due to cholangitis, acute pancreatitis may also form part of history. (Physical examination is usually non-contributory). [speciality.medicaldialogues.in]
Pruritus. D. Jaundice. 3. Answer: A. Amber-colored urine. A: Amber-colored urine is seen in patients with urinary tract infection. B, C, D: Clay-colored feces, pruritus, and jaundice are clinical manifestations of common bile duct obstruction. 4. [nurseslabs.com]
[…] common): history of cholelithiasis Clinical features [18][7] Colicky RUQ/epigastric pain More severe and prolonged (> 6 hours) than in cholelithiasis Postprandial Nausea, vomiting Signs of extrahepatic cholestasis: jaundice, pale stool, dark urine, pruritus [amboss.com]
Psychiatrical
- Hunger
By JEN GUNTER Well Photo Credit Illustration by Celia Jacobs Outrunning Hunger Intense exercise may change the way certain neurons influence our appetite and metabolism. [nytimes.com]
- Anger
This product can clear anger, vent Yu heat, gas pain, and enhance the analgesic effect with the use of fumarate. [0022] 以上诸药配伍,共奏清解郁热、利胆通腑、溶石排石、行气止痛之功。 [patents.google.com]
Urogenital
- Dark Urine
urine, light colored stools ② ALP ↑, bilirubin(direct) ↑, aminotransferase ↑ ③ Bilirubin은 15mg/dl 이상으로는 상승하지 않음 * 20mg/dl 이상의 bilirubin, Courvoisier’s sign → neoplastic obstruction CBD stone은 무증상이더라도 발견되면 반드시 치료! [m.blog.naver.com]
Patients may also experience clay-colored stools and dark urine. [jamanetwork.com]
Dark urine. Symptoms associated with Pancreatitis. Charcot's Triad:[edit] Clasically seen in common-bile-duct-stone. Fluctuating Jaundice + Pain RUQ + Fever (with rigors) Examination:[edit] O/E: Icterus (+). Febrile. P/A: RUQ tenderness. NB! [en.wikibooks.org]
urine and acholic stool can be seen in complete or near-complete biliary obstruction. [clinicaladvisor.com]
If a stone completely blocks the ducts of the gallbladder, liver, common bile duct or pancreas, other symptoms may include: Nausea Fever Chills Yellow skin or eyes (from the build up of bilirubin, a waste product in blood) Dark urine Itching Fatigue Weight [virginiamason.org]
- Hematuria
The energy setting and number of discharges delivered is dependent on the device used and patient tolerance as the main adverse effects include pain, local hematoma formation, cardiac arrhythmias, biliary obstruction, hemobilia and hematuria [31]. [sages.org]
Workup
Choledocholethiasis is often diagnosed based on a clinical suspicion rather than a specific manifestation. Complete blood picture is a general laboratory procedure suggested for suspected gallstones and an elevated white blood cell count suggests infection as in cholangitis and pancreatitis. Hyperbilirubinemia and elevated serum alkaline phosphatase can be noted in liver function tests and indicate intraductal bile stasis. These results often warrant further investigation, particularly imaging studies.
Transabdominal ultrasonography is the most common imaging method for detecting gallstones. In choledocholethiasis, ultrasonography may reveal dilatation of the duct, an indicator of duct obstruction. Endoscopic ultrasonography is specific in 95% of the patients and sensitive in 94% of the patients in detecting bile duct stones. But this procedure requires special skill and expertise. Endoscopic retrograde cholangiopancreatography (ERCP) is useful in diagnosis and management of stones in common bile duct. It is usually performed in combination with sphincterotomy [7]. Magnetic resonance cholangiopancreatography is a technique with 93% specificity and 94% sensitivity in detecting bile duct stones and useful in detecting stones that are missed in ultrasonography. This method is often the confirmatory in diagnosis and can be used for directing a patient for therapeutic ERCP. In patients where ERCP is difficult, percutaneous transhepatic cholangiography is recommended. This is particularly true of patients who had bile duct stones previously.
Serum
- Alkaline Phosphatase Increased
Pathophysiology [ edit ] This obstruction may lead to jaundice, elevation in alkaline phosphatase, increase in conjugated bilirubin in the blood and increase in cholesterol in the blood. [en.wikipedia.org]
Laboratory
- Leukocytosis
Individuals with acute cholecystitis present with right upper quadrant pain, fever, and leukocytosis. Management includes supportive care and cholecystectomy. [ncbi.nlm.nih.gov]
Leukocytosis and Bacteremia are frequently present There is no need for empiric abx in patients with choledocholithiasis in the absence of cholangitis Rather than antibiotics, the definitive treatment for uncomplicated choledocholithiasis is stone removal [errolozdalga.com]
Fever and leukocytosis further suggest acute cholangitis. [msdmanuals.com]
[…] age) • Right upper quadrant pain • Painless jaundice • Both pain and jaundice • Fever • Asymptomatic • Nausea • Vomiting • Anorexia • Conjugated hyperbilirubinemia (for choledocholithiasis) • Elevated alkaline phosphatase (for choledocholithiasis) • Leukocytosis [accesssurgery.mhmedical.com]
Treatment
ERCP, with spnincterotomy in conjunction with gallstone removal, is the treatment of choice in most of the cases of choledocholethiasis [8]. This helps in reducing the pressure and to drain the biliary tree. Those with severe symptoms, as in cholangitis, may require antibiotics treatment with ERCP. This procedure has reduced the need for a surgical procedure by 0.2%.
Dissolution is an option in patients with asymptomatic duct stones. Those who have symptomatic bile duct stones, should consult for both surgical and non-surgical options. Dissolution may be considered in many cases, particularly in those where surgery may be a risk. Dissolution therapy is suggested in patients with functioning gallstone, but with multiple gallstones that are radiolucent. Contact dissolution, oral bile salt therapy, and lithotripsy are some of the dissolution methods used. The presence of multiple stones increases the surface area for contact with the dissolution agent. Patients who are resistant to endoscopic removal may opt for lithotripsy.
Those who have choledocholethiasis and gallstones, may opt for cholecystectomy. Intraoperative cholangiography is performed along with cholecystectomy to remove stones from the bile duct. Choledochoduodenostomy, in which a fistula between bile duct and adjacent duodenum allows the passage of stone into the proximal part of intestine, may also be used. Laparoscopic cholecystectomy is a less invasive procedure for removing stones from the duct and gallbladder [9]. Cholecystostomy is performed by radiologists under a CT scan guidance to place a drainage tube in the gallbladder [10]. This method helps to improve the symptoms by draining the bile.
Prognosis
Choledocholethiasis is not associated with increased mortality or morbidity. About half of the patients with this condition remain asymptomatic, but some of the complications may require immediate treatment or can become life threatening. Cholangitis is a complication that may require immediate treatment. If left untreated it may be fatal for the patient. Pancreatitis is another severe complication that requires immediate attention.
Etiology
Pathogenesis and risk factors of choledocholethiasis vary with the type of stone. Secondary stones are mostly cholesterol gallstones that form in the gallbladder and then migrate to the bile duct. Obesity, pregnancy, gallbladder stasis, certain medications and some genetic factors increase the risk of developing choledocholethiasis. Metabolic syndrome leads to increased secretion of cholesterol and thus elevates the risk of developing this condition. Increased levels of progesterone may lead to gallbladder stasis, allowing concentration of bile. Injuries of spinal cord, sudden weight loss with severe diet restriction, and prolonged parenteral nutrition also cause gallbladder stasis. Certain medications tend to increase secretion of cholesterol in bile while some others decrease the emptying of gallbladder, both increasing the risk of developing gallstones. Estrogen, fibrate hypolipidemic drugs and somatostatins increase the risk of gallstones by these methods. Certain genes are also linked to increased risk of choledocholethiasis [2].
Pigmented stones form when there is intraductal stasis of bile. Patients with biliary strictures after surgery or choledochal cysts have reduced mobility of the bile in the ducts with bacterial colonization. Both the conditions favor development of gall stones in the duct. Those who have increased rate of hemolysis have high turnover of heme and intraductal stasis, and develop black or brown pigmented gallstones. Patients with sickle cell anemia, beta-thalassemia, and spherocytosis have increased hemolysis and thus increased risk of pigmented, primary stones. Infestation of biliary flukes lead to the formation of biliary strictures, favoring formation of pigmented stones. These stones are most commonly seen in East Asia where biliary fluke infestation is prevalent. Diseases affecting reabsorption of bile salts, including Crohn disease and ileal resection, increase the risk of gall stones.
Epidemiology
About 70-80% of cases are caused by secondary stones that develop in the gallbladder and then move to the bile ducts. It is interesting to note that about 15% of the patients with cholecystolithiasis have stones in bile ducts and around 80%-95% of the patients with choledocholethiasis have stones in the gallbladder.
A number of factors, including ethnicity, comorbidities, gender and genetics, affect the prevalence of this condition. In general, around 20% of the population have gallstones. The prevalence is found to be lower in Asia and Africa [3]. Frequency of bile duct stones increases with age. It was found to range from 5% in 30 year old to 50% in people in the age group of 75 to 80 years. About 60% of the patients above the age of 60 years who undergo cholecystectomy develop gallstones. Presence of stones in children is rare, other than in those having congenital disorders. Incidence of gall stones is 2-3 times more among women when compared to men and this may be attributed to the presence of hormone estrogen [4]. Native American population, Hispanics and North European population have an increased incidence of gallstones [5].
Pathophysiology
When bile concentrates in the gallbladder or the duct, it results in the precipitation and crystallization of certain components, forming stones. Crystals in the bladder or duct may get entrapped in the mucus forming sludge. Stones may grow or fuse with other stones to form larger gallstones. Complications arise when these stones obstruct the ducts and gallbladder.
One of the major component that leads to the formation of stones is cholesterol. When the proportion of this substance increases beyond normal in the bile, it becomes saturated with cholesterol leading to the formation of cholesterol monohydrate crystals. Factors that determine the formation of cholesterol stones are:
- Amount of cholesterol secreted in the bile
- Degree of concentration of bile
- Extent of bile stasis
During severe hemolysis, concentration of bilirubin in the bile increases considerably, resulting in crystallization of calcium bilirubinate which over a period of time oxidizes and forms dark colored stones. Bacterial infection also lead to crystallization of bilirubin in the bile. Calcium precipitates formed by bacterial infection are dark brown in color and are mostly formed in the bile ducts. Infection of the cholesterol stones with bacteria may cause mucosal inflammation in the gallbladder. In some cases, these stones may accumulate calcium salts or calcium bilirubinate forming mixed stones. These stones may be large and are usually visible in X-ray imaging.
Prevention
Gall stones can be prevented using ursodeoxycholic acid, particularly in high-risk conditions. The recommended dose is 60mg/day. Diet containing less fat is also a good step to decrease the chances of gall stones. Patients who had choledocholethiasis once have chances of recurrence. Moderate physical activity and diet with increased content of fiber and lesser saturated fat reduce the risk of stones in gall bladder.
Summary
Choledocholethiasis, or bile duct stones as they are commonly known as, refers to the presence of gallstones in common bile duct. These stones may lead to cholangitis, biliary obstruction, biliary colic or pancreatitis. Some patients may be asymptomatic as the stones pass into the duodenum or remain in the duct. Stones found in the duct may be of classified into:
- Primary stones (form in the bile duct)
- Secondary stones (form in gall bladder and then move into the duct)
- Residual stones (stones left over after cholecystectomy)
- Recurrent stones (form 3-4 years after the surgery)
Gallstones are common in the general population, and about 8-10% of the people with gallstones develop choledocholethiasis. It is more prevalent among patients who undergo cholecystectomy [1]. Choledocholethiasis usually occurs due to the passage of gallstones from the gallbladder to the common bile duct. This passage may obstruct the flow of bile and result in biliary colic. And if the obstruction persists, it may lead to inflammation of the gallbladder. Stagnation of bile in the duct may result in infection of the duct, cholangitis. Treatment of the disease depends on severity. Surgical intervention may be needed if obstruction is symptomatic.
Patient Information
Choledocholethiasis, or bile duct stones, refers to the presence of stones in the bile duct. These stones usually form in the gallbladder and then migrate to bile duct. In some cases, stones may form in the duct directly. About 15% of the people who have gallstones develop bile duct stones. Gallstones are generally formed from two components in bile – cholesterol and pigments. These stones may block the duct and result in jaundice. In some cases the stone may move into the intestine without causing any further complications. Some of the factors that increase the risk of developing duct stones include high serum cholesterol levels, increased age, obesity, rapid loss of weight, and parenteral nutrition. Some hereditary diseases which result in hemolysis may also lead to the formation of stones in the gallbladder and ducts.
As bile is blocked in the duct, it leads to jaundice and other complications. If the bile is stagnant in the duct, it may lead to infection and affect other organs like liver and pancreas. With the progression of the disease, liver may undergo fibrosis resulting in cirrhosis. Stones in the bile duct may or may not cause any symptoms. If the bile duct is blocked, it may cause pain in the upper middle part of the abdomen. Fever, jaundice, loss of appetite and vomiting are some other common symptoms of this condition. If bacterial infection occurs in the stagnant bile, it may spread rapidly and lead to life threatening situation.
Blood tests, liver function tests, CT scan and ultrasound are some of the tests useful in detecting the presence of stones in the bile duct. Blood tests are useful in checking for infection and to understand the functioning of liver and pancreas. Relieving the blockage from the duct is the main focus of any treatment modality. Non-surgical methods of treating this condition include dissolution with medication and fragmentation using lithotripsy. Surgery is used to remove stones from gall and also from the ducts. In some cases a small cut is made in the duct to help them pass into the intestine or to remove them. Stenting the duct also helps to keep the lumen open for the passage of the bile. Moderate physical activity and changes in the diet with less of saturated fats may help in preventing choledocholethiasis.
References
- Cronan JJ. US diagnosis of choledocholithiasis: a reappraisal. Radiology. 1986;161 (1): 133-4.
- Portincasa P, Moschetta A, Palasciano G. Cholesterol gallstone disease. Lancet. 2006;368(9531):230-9.
- Halldestam I, Kullman E, Borch K. Incidence of and potential risk factors for gallstone disease in a general population sample. Br J Surg. 2009;96(11):1315-22.
- Wang HH, Liu M, Clegg DJ, Portincasa P, Wang DQ. New insights into the molecular mechanisms underlying effects of estrogen on cholesterol gallstone formation. Biochim Biophys Acta. 2009;1791(11):1037-47.
- Shaffer EA. Epidemiology and risk factors for gallstone disease: has the paradigm changed in the 21st century?. Curr Gastroenterol Rep. 2005;7(2):132-40.
- Gilani SN, Bass G, Leader F, Walsh TN. Collins' sign: validation of a clinical sign in cholelithiasis. Ir J Med Sci. 2009; 178(4):397-400.
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