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Symptoms, diagnosis and endoscopic management of common bile duct stones

https://doi.org/10.1016/j.bpg.2006.03.002Get rights and content

Bile duct stones (BDS) are often 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 majority of BDS can be diagnosed by transabdominal ultrasound, computed tomography, endoscopic ultrasound or magnetic resonance cholangiography 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. 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.

Section snippets

Symptoms and signs of common bile duct stones

The symptoms and signs of common bile duct stones (CBDS) are variable and can range from being completely asymptomatic to complications such as biliary colic, jaundice, cholangitis or pancreatitis. Whilst complications of retained bile duct stones (BDS) are common, a proportion of CBDS remain asymptomatic and do not result in any complications. However, the natural history of asymptomatic BDS is difficult to determine. Studies have estimated the prevalence of asymptomatic BDS to be between 5.2%

Clinical differential diagnosis

The differential diagnosis of CBDS will be dependant on the clinical presentation.

Laboratory tests

Patients presenting with CBDS often have cholestatic liver function tests (LFT's). In the study by Anciaux, elevated serum gamma glutamyl transpeptidase (GGT) and alkaline phosphatase (ALP) were the most frequent biochemical abnormalities in patients with symptomatic choledocholithiasis (increased in 94% and 91% of cases, respectively).14 Serum bilirubin levels may be markedly elevated depending on whether the obstruction of the bile duct is complete or incomplete. In the same study by Anciaux,

Is there always an indication to treat CBD stones?

As previously discussed, CBDS detected in symptomatic patients, have a high rate of complications if left in situ (approximately 50% of patients will subsequently develop jaundice, cholangitis, biliary colic or pancreatitis). The true natural history of asymptomatic bile duct stones is unknown but they appear to cause fewer complications than CBDS detected in symptomatic patients. In contrast, in asymptomatic gallstones, a cholecystectomy would not be recommended, as the cumulative risk of

Role of medical therapy?

The role of medical therapy will discuss the role of ursodeoxycholic acid (UDCA). The role of other non-surgical treatments of CBDS such as extracorporeal shockwave lithotripsy (ESWL) will be discussed below.

The use of UDCA (and chenodeoxycholic acid) has only been shown to dissolve cholesterol containing stones. However, approximately 85–95% of patients in the Western World will have cholesterol stones. The first report of using bile salt acids to dissolve cholesterol stones was reported in

ERC (sphincterotomy or pneumatic dilatation)

Endoscopic biliary sphincterotomy (EST) at ERC was first described in 1974 and was initially advocated for elderly patients or patients with other co-morbid illness excluding them from surgical management. However, since this time, EST has become widespread in the practice for the removal of CBDS. The complications of EST have been previously well described. The use of EST, particularly in younger patients, led to concern over the long term sequelae of a disrupted sphincter of Oddi caused by

Mechanical lithotripsy

Stone removal from the common bile duct may be technically difficult due to factors such as the size of the stone (>2 cm), impaction of the stone in a non-dilated bile duct, stones above a bile duct stricture or a narrowed retro-pancreatic portion of the distal CBD. In these circumstances, mechanical lithotripsy (ML) is commonly used. The standard ML device is a basket inserted through a plastic and then a metallic sheath, which is inserted through the scope. The Olympus BML range and Monolith

Pulsated laser lithotripsy

Laser lithotripsy uses an amplified light energy, at a particular wavelength, which is focused into a single beam and directed onto a stone within the bile duct. This causes plasma formation on the surface of the stone, allowing more absorption of laser light, and results in an acoustic shockwave that can fragment the stone. Laser lithotripsy can be performed under direct vision using cholangioscopy using mini scopes or can be performed under fluoroscopic control using standard equipment. More

Stenting as definite treatment of bile duct stones?

Insertion of an endoprothesis may be required on a temporary basis for difficult to retrieve CBDS. Studies have shown that the majority of CBDS reduce in size following stenting and therefore should be easier to remove at repeat ERCP.93 However, insertion of an endoprothesis as a definitive treatment of CBDS, without any further subsequent intervention, may be considered but should be limited to patients with severe co-morbid illness. Any such illness should make any subsequent ERC procedures

Extracorporeal shockwave lithotripsy

Extracorporeal shockwave lithotripsy (ESWL) was first used treating gallstones in 1980s following its successful use in fragmenting renal calculi.97 Shock waves are generated outside the body using electrohydraulic, electromagnetic or piezoceramic shockwave systems. First generation lithotriptors required patients to be immersed in a water bath and often required general anaesthesia. Subsequent generation of lithotriptors do not require immersion in a water bath and can be performed under

Chemical dissolution therapy

Following published reports of chemical dissolution therapy for gallstones, the technique of chemical contact dissolution for retained common bile duct stones was first published in 1947.102 However, due to the side effects of the chemical used (diethyl ether), the procedure was not widely practiced. The discovery of mono-octanoin as a cholesterol stone dissolving agent, led to several reports of its use in difficult to remove CBDS. Palmer and Hofmann collated a series of case reports on its

Summary

Symptomatic BDS commonly cause significant morbidity and attempt at stone removal should be attempted if possible. Complications of CBDS include biliary colic, jaundice, cholangitis and pancreatitis. Investigations aimed to predict the presence of stones within the bile duct include serum bilirubin, AST, ALP, common bile duct diameter and age as independent predictors of choledocholithiasis. TUS is a sensitive test in detecting bile duct dilatation but the sensitivity is reduced in its ability

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