Choledocholithiasis K80.50

Synonyms

Common bile duct stones; CBD; stones in the common bile duct;

First described by

Common bile duct stones were first described clinically with the introduction of sonography in the 1970s (Krombach 2015).

The drainage of stagnant bile by insertion of a catheter using the Seldinger technique was first introduced by Molnar and Stockhum in 1974 (Pointner 2011).

Laparoscopic cholecystectomy was first described by Erich Mühe in 1985. Nowadays, the surgical procedure is one of the standard procedures in visceral surgery (Scholz 2017).

Choledocholithiasis (CBD) refers to the presence of gallstones in the choledochal duct (Hwan-Park 2018).

Bile duct stones are differentiated between:

- primary CBDs

Primary CBDs form directly in the choledochal duct. They are brown pigment stones (Herold 2022).

- Other CBDs

These form in the gallbladder and then migrate into the choledochal duct. These are most commonly pigment stones with a cholesterol core (Herold 2022).

Choledocholithiasis is relatively common. The prevalence is between 10-20% in patients with cholelithiasis (Hwan-Park 2018).

According to Gerok (2007), CBDs are found in 5% of 30-year-olds and 45% of 80-year-olds.

Bacterial or (more rarely) parasitic infections play a role in the development of primary CBDs, as well as functional or anatomical changes in the bile ducts.

For secondary CBDs, the so-called rule of 6 applies: female, fair fat, forty, fertile, family (Herold 2022). Secondary CBDs have the same risk factors and causes as cholelithiasis (Gerok 2007) such as:

- increasing age

- gender (w: m 2 - 3: 1)

- hereditary factors

- obesity (20% overweight doubles the risk of cholelithiasis)

- diet

Both fasting and high cholesterol, low fiber diets play a role, as does parenteral nutrition.

- Bile acidosis syndrome

- drug therapy with e.g. fibrates or somatostatin analogues (Herold 2022)

Choledocholithiasis may also occur in cases of idiopathic pancreatitis (Beyer 2021).

Often CBDs remain asymptomatic (Lehmann 2022).

Otherwise, the following symptoms may exist:

- intermittent acute pain in the upper abdomen

- Icterus (Kasper 2015)

- dark urine

- acholic stool (Lehmann 2022)

The European Society for Gastrointestinal Endoscopy (ESGE) recommends liver function tests and abdominal ultrasonography as the first steps in cases of choledocholithiasis. Further diagnosis should include endoscopic ultrasonography (EUS), (MRCP) magnetic resonance cholangiopancreaticography, or ERCP (Manes 2019).

If there is a moderate probability of choledocholithiasis after EUS, ERCP can also be performed directly instead of MRCP, since therapeutic measures are possible simultaneously with ERCP (Lehmann 2022).

Sonography:

Sonographically, choledocholithiasis can be visualized by abdominal ultrasonography with a sensitivity between 50 - 100 %, as it strongly depends on the examiner and the size of the concrements (Beyer 2021).

Dilatation of the choledochal duct is an important sonographic criterion with a specificity of 96% (Gutt 2018). However, at an early stage, the dilatation id R. not yet presentable (Kasper 2015)

EUS:

Endosonography has the highest specificity of 95% in a prospective controlled study (Gutt 2018).

ERCP:

According to Kasper (2015), the most important diagnosis, the so-called gold standard, in cases of V. a. a choledocholithiasis is ERCP with a sensitivity and specificity of clearly > 90 % (Gutt 2018). At the same time, ERCP allows for immediate therapy in cases of choledocholithiasis (Kasper 2015).

However, as ERCP has a morbidity rate of 10% and a mortality rate of 1%, it should not be performed for purely diagnostic purposes (Lehmann 2022).

Therefore, if the findings are unclear, MRCP plus EUS is recommended first (Lehmann 2022). This can be used to diagnose choledocholithiasis in > 90% (Kasper 2015).

MRCP:

The specificity of MRCP alone is 73% (Gutt 2018).

Cholangiography:

This can be performed endoscopically, percutaneously, or intraoperatively (Kasper 2015). However, iv cholangiography has now lost much of its importance due to modern CT and MRI diagnostics (Lehmann 2022).

There is a logical increase in cholestasis parameters such as gamma-GT and alkaline phosphatase, and later also in bilirubin. Transaminases increase only with prolonged outflow obstruction (Lehmann 2022).

In V. a. A choledocholithiasis, the following laboratory values should be checked:

- Total bilirubin

- gamma GT

- alkaline phosphatase

- ALT (GPT) or

- AST (GOT)

- lipase (Gutt 2018)

In the case of occlusive icterus, the differential diagnosis may include:

- Lithiasis (in 69 %)

- Malignant (18 %)

- strictures

- benign papillary stenosis

- malformations (3 %)

- Parasites in very rare cases (Lehmann 2022)

Choledocholithiasis results in approximately 50% of affected individuals are difficulties such as:

- occlusive icterus

- acute cholangitis (Herold 2022). Here, with 28 - 70 %, choledocholithiasis is found as the most frequent cause of cholangitis. The lethality ranges from 3 - 10 % (Gutt 2018).

- Gallstone pancreatitis

This can occur when the stone passes through the papilla of Vater (Kasper 2015).

The ESGE (European Society for Gastrointestinal Endoscopy) recommends stone extraction for all patients with bile duct stones, regardless of any existing symptoms, for all patients fit enough to tolerate the procedure (Manes 2019), as serious complications can occur with choledocholithiasis (Gerok 2007).

One-stage endoscopic sphincterotomy with endoscopic papillary large balloon dilatation is recommended by ESGE. In case of failure of this therapy, mechanical lithotripsy is recommended (Tringali 2021).

Patients with proven choledocholithiasis and biliary pancreatitis should be treated with sphincterotomy by ERCP (Beyer 2021).

Another therapeutic measure is a two-stage procedure by ERCP with endoscopic biliary sphincterotomy performed before or after cholecystectomy (Lehmann 2022).

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