Overview
Definition:
Choledocholithiasis is the presence of gallstones within the common bile duct (CBD)
Transcystic exploration is a minimally invasive surgical technique used to remove these stones through the cystic duct remnant after cholecystectomy or sometimes as part of intraoperative cholangiography.
Epidemiology:
Choledocholithiasis occurs in 5-20% of patients undergoing cholecystectomy
The prevalence increases with age and the presence of symptomatic cholelithiasis
Risk factors include pigmented stones (more common in Asia), female gender, and obesity.
Clinical Significance:
Unresolved choledocholithiasis can lead to serious complications such as ascending cholangitis, biliary pancreatitis, and secondary biliary cirrhosis
Accurate diagnosis and effective stone removal are crucial for patient outcomes and preventing morbidity.
Clinical Presentation
Symptoms:
Right upper quadrant (RUQ) abdominal pain, often colicky or constant
Jaundice, presenting as yellowing of the skin and sclera
Fever and chills, suggestive of cholangitis
Nausea and vomiting
Anorexia.
Signs:
Jaundice on physical examination
Tenderness in the RUQ
Murphy's sign may be positive if associated cholecystitis is present
Palpable gallbladder (Courvoisier's sign) in cases of distal CBD obstruction due to malignancy or chronic stone impaction
Signs of sepsis: fever, tachycardia, hypotension in severe cholangitis.
Diagnostic Criteria:
Diagnosis is typically based on a combination of clinical suspicion, laboratory findings, and imaging
The Tokyo Guidelines 2018 provide consensus criteria for diagnosing acute cholangitis, which often coexists with choledocholithiasis, based on clinical, laboratory, and imaging findings.
Diagnostic Approach
History Taking:
Detailed history of abdominal pain characteristics (location, radiation, duration, aggravating/relieving factors)
Inquiry about fever, chills, nausea, vomiting, and changes in bowel habits or urine color
Past medical history including previous gallstone disease, pancreatitis, or cholangitis
Family history of gallstones.
Physical Examination:
Systematic abdominal examination, focusing on RUQ tenderness, guarding, and rebound tenderness
Assess for jaundice, and check for Courvoisier's sign
Evaluate for signs of systemic inflammatory response syndrome (SIRS) or sepsis.
Investigations:
Laboratory tests: Elevated serum bilirubin (conjugated and unconjugated), alkaline phosphatase (ALP), gamma-glutamyl transferase (GGT), and alanine aminotransferase (ALT) are highly suggestive
Amylase and lipase may be elevated if pancreatitis is present
Complete blood count (CBC) showing leukocytosis in cholangitis
Imaging: Abdominal ultrasonography is the initial modality, often revealing CBD dilation and stones
Magnetic Resonance Cholangiopancreatography (MRCP) is the gold standard for visualizing biliary anatomy and identifying CBD stones, offering excellent sensitivity and specificity
Endoscopic retrograde cholangiopancreatography (ERCP) is both diagnostic and therapeutic, allowing for stone extraction and sphincterotomy
Intraoperative cholangiography (IOC) via T-tube or laparoscopic cystic duct remnant can be used to confirm stone presence and patency.
Differential Diagnosis:
Peptic ulcer disease
Hepatitis
Pancreatitis
Appendicitis
Renal colic
Other causes of obstructive jaundice like cholangiocarcinoma or extrinsic compression of the CBD.
Management
Initial Management:
Pain control with analgesics
Intravenous fluids for hydration
Broad-spectrum antibiotics if cholangitis is suspected or confirmed (e.g., ceftriaxone plus metronidazole, or piperacillin-tazobactam)
Nasogastric tube insertion if significant vomiting or ileus is present.
Medical Management:
Antibiotics are crucial for treating ascending cholangitis
Analgesics for pain relief
Antiemetics for nausea and vomiting.
Surgical Management:
Laparoscopic cholecystectomy is the standard treatment for symptomatic cholelithiasis
If choledocholithiasis is diagnosed preoperatively or intraoperatively: 1
Laparoscopic common bile duct exploration (LCBDE) with or without choledochoscopy
2
Transcystic exploration: Stones are pushed into the gallbladder or extracted through the cystic duct remnant after cholecystectomy
This is preferred if the cystic duct is wide enough (>5mm) and stones are small/mobile
It avoids choledochotomy
3
Choledochotomy: Direct incision into the CBD for stone removal, followed by T-tube placement or primary closure with or without stenting
4
ERCP with sphincterotomy and stone extraction is often performed preoperatively or postoperatively, especially if LCBDE is unsuccessful or not feasible
Post-cholecystectomy patients with residual stones may undergo ERCP or repeat LCBDE.
Supportive Care:
Close monitoring of vital signs, urine output, and fluid balance
Nutritional support, often parenteral initially if oral intake is poor
Regular laboratory monitoring of liver function tests and inflammatory markers
Management of pain and nausea.
Complications
Early Complications:
Bleeding from the cystic duct stump or CBD
Biliary leak from the cystic duct stump or choledochotomy site
Injury to the hepatic artery or portal vein
Pancreatitis secondary to manipulation of the common bile duct
Retained stones in the CBD.
Late Complications:
Biliary strictures at the cystic duct stump or choledochotomy site
Recurrent choledocholithiasis
Cholangitis
Biliary cirrhosis if obstruction is prolonged or recurrent
Gallstone ileus (rare).
Prevention Strategies:
Thorough intraoperative cholangiography to identify all stones
Complete removal of stones during LCBDE or ERCP
Careful handling of the cystic duct stump
Prompt diagnosis and management of biliary leaks
Judicious use of T-tube or stenting in complex cases
Close follow-up.
Prognosis
Factors Affecting Prognosis:
Severity of cholangitis or pancreatitis at presentation
Success of stone clearance
Presence of underlying biliary strictures or liver disease
Patient's overall health status.
Outcomes:
With successful stone removal and management of complications, the prognosis is generally good
Most patients regain normal liver function
Recurrence is possible if pigment stones persist or new stones form
Long-term complications like strictures can significantly impact quality of life.
Follow Up:
Routine follow-up with liver function tests and ultrasound may be recommended, especially if there was significant biliary tract pathology or potential for recurrence
Patients should be advised to report any recurrence of pain, jaundice, fever, or other biliary symptoms.
Key Points
Exam Focus:
Indications for transcystic exploration vs
choledochotomy
Contraindications for transcystic approach (e.g., very wide CBD, impacted distal stones, tortuous cystic duct)
Role of ERCP vs
LCBDE
Management of retained stones
Tokyo Guidelines for cholangitis.
Clinical Pearls:
A wide cystic duct remnant (>5mm) is essential for successful transcystic exploration
Intraoperative cholangiography or choledochoscopy is key to confirming stone clearance
A negative cholangiogram does not entirely rule out stones, especially small ones or those impacted distally.
Common Mistakes:
Attempting transcystic exploration with a narrow cystic duct or large impacted stones, leading to failure and potential CBD injury
Inadequate follow-up imaging or clinical assessment, missing retained stones
Delayed antibiotic administration in cholangitis.