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Choledocholithiasis

Gallstones which have passed into the bile ducts.

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(Source: NIH - National Institute of Diabetes and Digestive and Kidney Diseases and National Library of Medicine)

What works? Research summarized

Evidence reviews

Gallstone Disease: Diagnosis and Management of Cholelithiasis, Cholecystitis and Choledocholithiasis

Gallstone disease is the term used in this guideline to refer to the presence of stones in the gallbladder or common bile duct and the symptoms and complications they cause. The following aspects of gallstone disease are included in this guideline: Asymptomatic gallbladder stones; symptomatic gallbladder stones, including biliary colic, acute cholecystitis, Mirrizi syndrome, and Xanthogranulomatous cholecystitis; common bile duct stones, including biliary colic, cholangitis, obstructive jaundice and gallstone pancreatitis; other complications of gallstones (such as gastric outlet obstruction, or gallstone ileus) and other conditions related to the gallbladder (such as gallbladder cancer, or biliary dyskinesia) are not included in this guideline.

Prophylactic cholecystectomy should be offered to patients whose gallbladders remain in‐situ after endoscopic sphincterotomy and common bile duct clearance

Surgical removal of the gallbladder is done routinely. Stones in the common bile duct usually come from the gallbladder and can be harmful. The usual treatment for gallstones that are in the common bile duct is endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy. ERCP is an endoscopic procedure to remove stones from the common bile duct. More stones may enter the common bile duct from the gallbladder but it is not clear if the gallbladder should be removed preventively (prophylactic cholecystectomy) or if a wait‐and‐see policy (cholecystectomy deferral) would be better. We included 5 randomised trials with 662 participants out of 93 publications identified through the literature searches. The number of deaths was 47 in the wait‐and‐see group (334 patients) compared with 26 in the prophylactic cholecystectomy group (328 patients). This review of randomised clinical trials suggests that early removal of the gallbladder decreases the risk of death or of complications from gallstones. The number of patients (662) reviewed in this report prevents some of the subgroup analyses from being conclusive. Further clinical trials, particularly of high‐risk patients, would solve this problem.

Systematic review and meta-analysis of minimally invasive techniques for the management of cholecysto-choledocholithiasis

BACKGROUND: The optimal management of patients with symptomatic gallstones and possible or proven common bile duct (CBD) stones and gallstones is still evolving. Today a number of options exist: preoperative endoscopic retrograde cholangiopancreatography (pre-op ERCP), laparoscopic cholecystectomy (LC) combined with intraoperative endoscopic sphincterotomy (IOES), laparoscopic common bile duct exploration (LCBDE) and postoperative ERCP (post-op ERCP). This meta-analysis was done to compare these management options and determine if any single option was clearly superior.

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Summaries for consumers

Prophylactic cholecystectomy should be offered to patients whose gallbladders remain in‐situ after endoscopic sphincterotomy and common bile duct clearance

Surgical removal of the gallbladder is done routinely. Stones in the common bile duct usually come from the gallbladder and can be harmful. The usual treatment for gallstones that are in the common bile duct is endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy. ERCP is an endoscopic procedure to remove stones from the common bile duct. More stones may enter the common bile duct from the gallbladder but it is not clear if the gallbladder should be removed preventively (prophylactic cholecystectomy) or if a wait‐and‐see policy (cholecystectomy deferral) would be better. We included 5 randomised trials with 662 participants out of 93 publications identified through the literature searches. The number of deaths was 47 in the wait‐and‐see group (334 patients) compared with 26 in the prophylactic cholecystectomy group (328 patients). This review of randomised clinical trials suggests that early removal of the gallbladder decreases the risk of death or of complications from gallstones. The number of patients (662) reviewed in this report prevents some of the subgroup analyses from being conclusive. Further clinical trials, particularly of high‐risk patients, would solve this problem.

Endoscopic ultrasound versus magnetic resonance cholangiopancreatography for the diagnosis of common bile duct stones

Bile, produced in the liver and stored temporarily in the gallbladder, is released into the small bowel on eating fatty food. The common bile duct (CBD) is the tube through which bile flows from the gallbladder to the small bowel. Stones in the CBD (CBD stones) are usually formed in the gallbladder before migration into the bile duct. They can obstruct the flow of bile leading to jaundice (yellowish discolouration of skin, whites of the eyes, and dark urine), infection of the bile (cholangitis), and inflammation of the pancreas (pancreatitis), which can be life threatening. Various diagnostic tests can be performed for the diagnosis of CBD stones. Depending upon the availability of resources, these stones are removed endoscopically (usually the case) or may be removed as part of the operation performed to remove the gallbladder (it is important to remove the gallbladder since the stones continue to form in the gallbladder and can cause recurrent problems). Prior to removal, invasive tests such as endoscopic retrograde cholangiopancreatography (ERCP) or intraoperative cholangiography (IOC) can be performed to detect CBD stones. However, before performing such invasive tests to diagnose CBD stones, non‐invasive tests such as endoscopic ultrasound (EUS) (using ultrasound attached to the endoscope) and magnetic resonance cholangiopancreatography (MRCP) are used to identify people at high risk of having CBD stones so that only those at high risk can be subjected to further tests.

Endoscopic retrograde cholangiopancreatography versus intraoperative cholangiography for the diagnosis of common bile duct stones

The liver has various functions. Production of bile is one of these functions. The common bile duct (CBD) is the tube through which bile flows from the gallbladder (where bile is temporarily stored) into the small bowel. Stones in the CBD (CBD stones) can obstruct the flow of bile from the liver into the small bowel. Usually such stones are formed in the gallbladder and migrate into the CBD. Obstruction of the flow of bile can lead to jaundice (yellowish discolouration of skin and white of the eyes, and dark urine), infection of the bile duct (cholangitis), and inflammation of the pancreas (pancreatitis), which can be life threatening. Various diagnostic tests can be performed to diagnose CBD stones. Depending upon the availability of resources, these stones are removed endoscopically (a tube inserted into the stomach and upper part of small bowel through mouth; usually the case), or may be removed as part of the laparoscopic operation (key hole surgery) or open operation performed to remove the gallbladder (cholecystectomy; it is important to remove the gallbladder since the stones continue to form in the gallbladder and can cause recurrent health problems). If the stones are removed endoscopically, presence of stones is confirmed by endoscopic retrograde cholangiopancreatography (ERCP) (injection of dye into the CBD using an endoscope) before endoscopic removal of CBD stones. Alternatively, intraoperative cholangiography (IOC) (injection of dye into the biliary tree during an operation to remove the CBD stones, usually combined with an operation to remove gallstones) can be performed to detect CBD stones prior to operative removal of the stones. We performed a thorough search for studies that reported the accuracy of ERCP or IOC for the diagnosis of CBD stones. The evidence is current to September 2012.

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Terms to know

Bile Ducts
Tubes that carry bile from the liver to the gallbladder for storage and to the small intestine for use in digestion.
Cholecystitis
Inflammation of the gallbladder.
Gallbladder
The organ that stores the bile made in the liver and that is connected to the liver by bile ducts. The gallbladder can store about 2 tablespoons of bile. Eating signals the gallbladder to empty the bile through the bile ducts to help the body digest fats.
Gallstones
Solid material that forms in the gallbladder or common bile duct. Gallstones are made of cholesterol or other substances found in the gallbladder. They may occur as one large stone or as many small ones, and vary from the size of a golf ball to a grain of sand.

More about Choledocholithiasis

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Other terms to know: See all 4
Bile Ducts, Cholecystitis, Gallbladder

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