Choledocholithiasis
Gallstone in the bile duct; Bile duct stone
Choledocholithiasis is the presence of at least one gallstone in the common bile duct. The stone may be made up of
The esophagus, stomach, large and small intestine, aided by the liver, gallbladder and pancreas convert the nutritive components of food into energy and break down the non-nutritive components into waste to be excreted.
A CT scan of the upper abdomen showing a fist-sized cyst of the left kidney and gallstones (the kidney cyst was found by chance; there were no symptoms).
About 15% of people with gallstones will develop stones in the common bile duct. The common bile duct is a small tube that carries bile from the gallbladder to the duodenum. Obstruction of the common bile duct may also lead to obstruction of the pancreatic duct because these ducts are usually connected. If the pancreatic duct is also obstructed, pancreatitis will likely develop.
The liver produces bile which aids in the digestion of fats. The bile travels through tiny canals which eventually drain through the common bile duct into the small intestine. The gallbladder stores excess bile that is not immediately needed for digestion.
The gallbladder is a muscular sac located under the liver. It stores and concentrates the bile produced in the liver that is not immediately needed for digestion. Bile is released from the gallbladder into the small intestine in response to food. The pancreatic duct joins the common bile duct at the small intestine adding enzymes to aid in digestion.
The biliary system is comprised of the organs and duct system that create, transport, store and release bile into the duodenum for digestion. Includes the liver, gallbladder and bile ducts (named the cystic, hepatic, common, and pancreatic duct).
Causes
About 1 in 7 people with gallstones will develop stones in the common bile duct. This is the small tube that carries bile from the gallbladder to the intestine.
Risk factors include a history of gallstones. However, choledocholithiasis can occur in people who have had their gallbladder removed.
Stones are great for tossing into a stream or using to line your flowerbeds. But they're not so great when they're trapped inside your gallbladder. If you've got pain in the upper part of your belly, a fever, or yellow skin, they could be signs that you've got gallstones. The stones that form in your gallbladder aren't made of rock. Usually, they're made of cholesterol, a type of fat in your blood. Or, they could be made from a substance called bilirubin, which is processed in your liver. Gallstones can be as small as a grain of sand, or as big as a golf ball. You're more likely to get gallstones if you're over age 40, or if you have a chronic condition like diabetes, anemia, or cirrhosis of the liver. People who've had weight-loss surgery, or who went on a crash diet and lost weight very quickly can also develop gallstones. Gallstones are more common in women than in men, and they may run in families. So, how do you know if you have gallstones? Well, you might not realize it, because often gallstones don't cause any pain. They're often found accidentally during an x-ray or surgery to treat another condition. If the gallstone is very large, though, it may get stuck in one of the tubes, called ducts, which connect to the gallbladder. Then you'll probably feel a sharp or cramping pain in the upper right or middle part of your abdomen. You may also have a fever and feel sick to your stomach. Your doctor can do an ultrasound, or other scan of the gallbladder area to find out if gallstones are causing your pain. You may also have blood tests to check your liver function and to see if your bilirubin levels are too high. You may not need to treat gallstones, unless they're causing symptoms. If that's the case, your doctor will recommend treatment which is usually surgery to remove them. Often, this is done with a laparoscopic procedure that removes the gallstone through very small cuts or incisions. Normally, you can go home the same day as your surgery, or the next day. Most people don't need to have their whole gallbladder removed, unless they have complications, like a blocked duct. There is also medicine that can dissolve cholesterol gallstones, but it isn't that effective because it can take two years or more to work, and often the stones form again after you're done taking it. You can't really prevent gallstones, except by avoiding rapid weight loss or health conditions that can cause gallstones such as obesity, diabetes, or cirrhosis. But if you do get them, gallstones are pretty easy to treat. Most people don't have any symptoms or complications from them, and those who do have symptoms usually recover completely and don't get gallstones again after their surgery. It's important that you call your doctor if you are having abdominal pain, yellow skin or eyes, so you can find out for sure whether you have gallstones, and get them treated.
Symptoms
Often, there are no symptoms unless the stone blocks the common bile duct. Symptoms may include:
- Pain in the right upper or middle upper abdomen for at least 30 minutes. The pain may be constant and intense. It can be mild or severe.
- 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 retrograde cholangiography (ERCP)
- Endoscopic ultrasound
- Magnetic resonance cholangiopancreatography (MRCP)
- Percutaneous transhepatic cholangiogram (PTCA)
Your health care provider may order the following blood tests:
- Bilirubin
- Complete blood count (CBC)
- Liver function tests
- Pancreatic enzymes (amylase or lipase)
Treatment
The goal of treatment is to relieve the blockage.
Treatment may involve:
- Surgery to remove the gallbladder and stones
ERCP and a procedure called a sphincterotomy, which makes a surgical cut into the muscle in the common bile duct to allow stones to pass or be removed
Outlook (Prognosis)
Blockage and infection caused by stones in the biliary tract can be life threatening. Most of the time, the outcome is good if the problem is detected and treated early.
Possible Complications
Complications may include:
- Biliary cirrhosis
- Cholangitis
- Pancreatitis
When to Contact a Medical Professional
Contact 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
References
Fogel EL, Sherman S. Diseases of the gallbladder and bile ducts. In: Goldman L, Schafer AI, eds. Goldman-Cecil Medicine. 26th ed. Philadelphia, PA: Elsevier; 2020:chap 146.
Pattni C, Zenlea T. Choledocholithiasis. In: Ferri FF, ed. Ferri's Clinical Advisor 2023. Philadelphia, PA: Elsevier; 2023:368-369.
Radkani P, Hawksworth J, Fishbein T. Biliary system. In: Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 21st ed. St Louis, MO: Elsevier; 2022:chap 55.
Version Info
Last reviewed on: 5/2/2023
Reviewed by: Michael M. Phillips, MD, Emeritus Professor of Medicine, The George Washington University School of Medicine, Washington, DC. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.
