Journal List > Korean J Gastroenterol > v.71(5) > 1094725

Park: The Management of Common Bile Duct Stones

Abstract

Common bile duct (CBD) stone is a relatively frequent disorder with a prevalence of 10–20% in patients with gallstones. This is also associated with serious complications, including obstructive jaundice, acute suppurative cholangitis, and acute pancreatitis. Early diagnosis and prompt treatment is the most important for managing CBD stones. According to a recent meta-analysis, endoscopic ultrasonography and magnetic resonance cholangiopancreatography have high sensitivity, specificity, and accuracy for the diagnosis of CBD stones. Endoscopic ultrasonography, in particular, has been reported to have higher sensitivity between them. A suggested management algorithm for patients with symptomatic gallstones is based on whether they are at low, intermediate, or high probability of CBD stones. Single-stage laparoscopic CBD exploration and cholecystectomy is superior to endoscopic retrograde cholangiopancreatography (ERCP) plus laparoscopic cholecystectomy with respect to technical success and shorter hospital stay in high risk patients with gallstones and CBD stones, where expertise, operative time, and instruments are available. ERCP plus laparoscopic cholecystectomy is usually performed to treat patients with CBD stones and gallstones in many institutions. Patients at intermediate probability of CBD stones after initial evaluation benefit from additional biliary imaging. Patients with a low probability of CBD stones should undergo cholecystectomy without further evaluation. Endoscopic sphincterotomy and endoscopic papillary balloon dilation in ERCP are the primary methods for dilating the papilla of Vater for endoscopic removal of CBD stones. Endoscopic papillary large balloon dilation is now increasingly performed due to the usefulness in the management of giant or difficult CBD stones. Scheduled repeated ERCP may be considered in patients with high risk of recurrent CBD stones.

References

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Table 1.
A Proposed Strategy to Assign Risk of Choledocholithiasis in Patients with Symptomatic Cholelithiasis Based on Clinical Predictors13
Predictors of choledocholithiasis
 Very strong
  CBD stone on transabdominal US
  Clinical ascending cholangitis
  Bilirubin >4 mg/dL
 Strong
  Dilated CBD on US (>6 mm with gallbladder in situ)
  Bilirubin 1.8–4 mg/dL
 Moderate
  Abnormal liver biochemical test other than bilirubin
  Age older than 55 years
  Clinical gallstone pancreatitis
 Assessing a likelihood of choledocholithiasis based on clinical predictors
  Presence of any very strong predictor High
  Presence of both strong predictors High
  No predictors present Low
  All other patients Intermediate

CBD, common bile duct; US, ultrasonography.

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