Guideline sources The following summarized guidelines for the evaluation and management of choledocholithiasis are prepared by our editorial team based on guidelines from the Danish Surgical Society (DSS 2022), the World Society of Emergency Surgery (WSES 2020), the American Society for Gastrointestinal Endoscopy (ASGE 2019; 2015; 2011), the American College of Radiology (ACR 2019), the British Society of Gastroenterology (BSG 2017), and the European Association for the Study of the Liver (EASL 2016). 1 2 3 4 5 6 7 9 10 10 10 10 Definition Choledocholithiasis is the presence of stones within the common bile duct, characterized by RUQ pain, nausea, and vomiting. 10 Epidemiology https://web.pathway.md/diseases/rec8FeF0Sk5yiG3JR 1/10 6/29/23, 3:51 AM Choledocholithiasis Pathway Choledocholithiasis is caused by biliary stones, which can be divided into cholesterol (> 70% cholesterol), mixed (30%-70% cholesterol), and pigmented (< 30% cholesterol) stones. 10 Disease course Choledocholithiasis causes clinical manifestations of RUQ pain, nausea, vomiting. Disease complications include jaundice, acute pancreatitis, and acute cholangitis. 10 Prognosis and risk of recurrence Percutaneous biliary stone procedures in choledocholithiasis are associated with a mortality rate of 1.4%. 10 Calculator Calculator Pathway ASGE/SAGES criteria for stratific CholeS score for duration of lap Choledoc Managemen Guidelines 1. Classification and risk stratification Risk stratification: consider stratifying the risk of common bile duct stones according to the proposed classification modified from the ASGE and the SAGES guidelines. C 2. Diagnostic investigations Initial evaluation: As per WSES 2020 guidelines, obtain LFTs (including ALT, AST, GGT, bilirubin, and ALP) and abdominal ultrasound to assess the risk of choledocholithiasis in patients with acute calculous cholecystitis. B Show 2 more As per BSG 2017 guidelines, obtain transabdominal ultrasound and LFTs in patients with suspected common bile duct stones. Recognize that normal results do not preclude further investigation if clinical suspicion remains high. B As per EASL 2016 guidelines, evaluate patients with jaundice, acute cholangitis, or acute pancreatitis for common bile duct stones. A Show 3 more MRCP/EUS: As per DSS 2022 guidelines, obtain MRCP or EUS for the diagnosis of choledocholithiasis before surgical treatment of patients with gallstone disease. B https://web.pathway.md/diseases/rec8FeF0Sk5yiG3JR 2/10 6/29/23, 3:51 AM Choledocholithiasis Pathway As per WSES 2020 guidelines, obtain preoperative imaging (with MRCP or EUS) or intraoperative cholangiography or laparoscopic ultrasound, depending on local expertise and availability, in patients with acute calculous cholecystitis and moderate risk for choledocholithiasis. A As per ASGE 2019 guidelines: Consider obtaining either MRCP or EUS (based on patient preference, local expertise, and availability of resources for test selection) to confirm the diagnosis in patients with intermediate risk of choledocholithiasis. C Consider obtaining MRCP or EUS for further evaluation of patients with intermediate-risk criteria of abnormal liver tests, age > 55 years, or dilated common bile duct on ultrasound. E As per BSG 2017 guidelines: Obtain MRCP or EUS (depending on individual suitability, availability of the relevant test, local expertise, and patient acceptability) for identifying common bile duct stones in patients with an intermediate probability of disease. B Consider obtaining MRCP or EUS as the next step of evaluation after transabdominal ultrasound and LFTs in patients with an intermediate probability of stones, unless the patient is proceeding directly to cholecystectomy supplemented by intraoperative cholangiography or laparoscopic ultrasound. C As per EASL 2016 guidelines, obtain further evaluation with MRCP (or EUS) in patients with an intermediate probability of common bile duct stones. B ERCP: As per WSES 2020 guidelines, obtain preoperative ERCP, intraoperative cholangiography, or laparoscopic ultrasound, depending on the local expertise and the availability of the technique, in patients at high risk for common bile duct stones. A As per ASGE 2019 guidelines, perform prompt ERCP in patients with the following high-risk criteria for choledocholithiasis: common bile duct stone on ultrasound or cross-sectional imaging TBIL > 4 mg/dL and dilated common bile duct ascending cholangitis. E Show 2 more As per BSG 2017 guidelines, reserve ERCP for patients with assessment results indicating a need for endoscopic therapy. B Show 4 more As per ASGE 2015 guidelines: Do not perform diagnostic ERCP for the evaluation of pancreaticobiliary-type pain in the absence of objective abnormalities on other pancreaticobiliary imaging or laboratory studies. D Do not perform routine ERCP before laparoscopic cholecystectomy in the absence of objective signs of biliary obstruction or stone. D https://web.pathway.md/diseases/rec8FeF0Sk5yiG3JR 3/10 6/29/23, 3:51 AM Choledocholithiasis Pathway 3. Diagnostic procedures Intraoperative cholangiography/laparoscopic ultrasound: As per WSES 2020 guidelines: Obtain intraoperative cholangiography or laparoscopic ultrasound, or preoperative imaging (with MRCP or EUS), depending on local expertise and availability, in patients with acute calculous cholecystitis and moderate risk for choledocholithiasis. A Obtain intraoperative cholangiography or laparoscopic ultrasound, or preoperative ERCP, depending on the local expertise and the availability of the technique, in patients at high risk for common bile duct stones. A As per BSG 2017 guidelines: Consider obtaining intraoperative cholangiography or laparoscopic ultrasound to detect common bile duct stones in patients suitable for surgical exploration or postoperative ERCP. C Consider obtaining intraoperative cholangiography or laparoscopic ultrasound in patients with an intermediate-to-high pre-test probability of common bile duct stones not having a formal preoperative diagnosis by ultrasound, MRCP, or EUS, although not mandatory for all patients undergoing cholecystectomy. C As per EASL 2016 guidelines, avoid obtaining routine or selective intraoperative cholangiography during cholecystectomy in patients at low risk of common bile duct stones. D 4. Medical management Ursedeoxycholic acid: consider initiating ursedeoxycholic acid as an adjunct to biliary stenting in the management of difficult stones. C Antibiotic prophylaxis: Consider initiating antibiotics in patients with acute cholangitis, immunosuppression, or when biliary drainage is predicted to be incomplete. C Avoid routine antibiotics unless cholangitis is present, biliary drainage is predicted to be incomplete, or the patient is immunosuppressed. D 5. Therapeutic procedures Stone removal: As per WSES 2020 guidelines, remove common bile duct stones, either preoperatively, intraoperatively, or postoperatively, according to the local expertise and the availability of several techniques. A As per BSG 2017 guidelines, perform stone extraction in patients diagnosed with common bile duct stones, if possible, especially in symptomatic patients. B https://web.pathway.md/diseases/rec8FeF0Sk5yiG3JR 4/10 6/29/23, 3:51 AM Choledocholithiasis Pathway As per ASGE 2011 guidelines, remove common bile duct stones when detected unless significant mitigating clinical circumstances are present. B Endoscopic sphincterotomy: As per ASGE 2019 guidelines, consider performing endoscopic sphincterotomy followed by large balloon dilation in patients with large bile duct stones. C As per BSG 2017 guidelines, obtain a CBC and INR or PT before ERCP in patients undergoing biliary sphincterotomy for ductal stones. Follow locally agreed guidelines for subsequent management if deranged clotting or thrombocytopenia is identified. B Show 2 more Biliary stenting: As per ACR 2019 guidelines, place an endoscopic internal biliary catheter with a removable plastic stent as an initial therapeutic procedure in patients with dilated bile ducts from choledocholithiasis. B As per ASGE 2019 guidelines, consider placing plastic and covered metal stents in patients with common bile duct stones refractory to initial endoscopic extraction, recognizing that these stents require planned exchange or removal. E As per BSG 2017 guidelines: Restrict the use of biliary stents as a sole treatment for common bile duct stones to a selected group of patients with limited life expectancy and/or prohibitive surgical risk. B Ensure adequate biliary drainage in patients with unextracted common bile duct stones. Use a short-term biliary stent followed by further endoscopy or surgery. B As per ASGE 2011 guidelines, place a plastic biliary endoprosthesis to ensure adequate drainage in cases of incomplete stone extraction or severe acute cholangitis. B Endoscopic papillary balloon dilation: As per ASGE 2019 guidelines, consider performing intraductal therapy or conventional therapy with papillary dilation, depending on local expertise, cost, and patient and physician preferences, in patients with difficult and large choledocholithiasis. C As per BSG 2017 guidelines: Perform endoscopic papillary balloon dilation as an adjunct to biliary sphincterotomy to facilitate the removal of large common bile duct stones. A Consider performing endoscopic papillary balloon dilation as an alternative to biliary sphincterotomy in selected patients, such as with an uncorrected coagulopathy or difficult biliary access due to altered anatomy, although endoscopic papillary balloon dilation without prior biliary sphincterotomy is associated with an increased risk of post-ERCP pancreatitis. Use an 8-mm diameter balloon when endoscopic papillary balloon dilation is performed without prior biliary sphincterotomy. B Percutaneous and EUS-guided approaches: As per BSG 2017 guidelines: https://web.pathway.md/diseases/rec8FeF0Sk5yiG3JR 5/10 6/29/23, 3:51 AM Choledocholithiasis Pathway Consider performing percutaneous or EUS-guided procedures as a means of facilitating subsequent ERCP when endoscopic cannulation of the bile duct is not possible with standard techniques including access papillotomy. B Reserve percutaneous radiological stone extraction and open duct exploration for the small number of cases where laparoscopic duct exploration and ERCP (supplemented by endoscopic papillary balloon dilation with prior sphincterotomy, mechanical lithotripsy, or cholangioscopy where necessary) fail or are not possible. B As per ASGE 2011 guidelines, do not perform primary percutaneous transhepatic management of common bile duct stones in patients with native anatomy, given that more expeditious alternatives with similar or better risk profiles exist. D Peroral approaches: As per BSG 2017 guidelines, consider performing cholangioscopy-guided electrohydraulic lithotripsy or laser lithotripsy when other endoscopic treatment options fail to achieve duct clearance. B As per ASGE 2015 guidelines, consider performing cholangioscopy as an adjunctive technique for the management of difficult bile duct stones not amenable to removal after sphincterotomy with or without balloon dilation or mechanical lithotripsy. C 6. Surgical interventions Cholecystectomy: As per DSS 2022 guidelines: Perform laparoscopic cholecystectomy combined with laparoscopic or endoscopic retrograde cholangiography-assisted common bile duct stone removal as a one-step procedure rather than a two-step procedure in patients with imaging confirmed choledocholithiasis. B Consider performing laparoscopic cholecystectomy in addition to common bile duct stone removal in high-risk patients with choledocholithiasis. C As per ASGE 2019 guidelines, consider performing cholecystectomy without intraoperative cholangiogram in patients with symptomatic cholelithiasis without risk factors. E As per BSG 2017 guidelines, perform cholecystectomy in all patients with common bile duct stones and gallbladder stones unless there are specific reasons for considering surgery inappropriate. A Laparascopic common bile duct exploration: As per BSG 2017 guidelines: Perform transcystic or transductal laparoscopic bile duct exploration for common bile duct stone removal in patients undergoing laparoscopic cholecystectomy. Recognize that there is no difference in efficacy, mortality, or morbidity when laparoscopic bile duct exploration is compared with perioperative ERCP, although laparoscopic bile duct exploration is associated with a shorter hospital stay. A https://web.pathway.md/diseases/rec8FeF0Sk5yiG3JR 6/10 6/29/23, 3:51 AM Choledocholithiasis Pathway Encourage training of surgeons in laparoscopic bile duct exploration to decrease the number of interventions required to manage common bile duct stones. B As per ASGE 2011 guidelines, perform laparoscopic common bile duct exploration as an alternative to endoscopic retrograde cholangiography as a first-line strategy for common bile duct stone removal in the setting of symptomatic cholelithiasis, in centers where surgical expertise is available. B 7. Specific circumstances Patients with acute cholangitis: As per BSG 2017 guidelines, perform urgent biliary decompression (endoscopic common bile duct stone extraction and/or biliary stenting) in patients with acute cholangitis not responding to antibiotic therapy or having signs of septic shock. Consider performing percutaneous radiological drainage as an alternative if ERCP is not possible. B As per EASL 2016 guidelines, perform early laparoscopic cholecystectomy within 72 hours after preoperative ERCP for choledocholithiasis in patients with simultaneous gallbladder and bile duct stones. B As per ASGE 2011 guidelines: Consider initiating antibiotics in patients with acute cholangitis. C Place a plastic biliary endoprosthesis to ensure adequate drainage in patients with severe acute cholangitis. B Patients with gallstone pancreatitis: As per ASGE 2019 guidelines, perform same-admission cholecystectomy in patients with mild gallstone pancreatitis. E As per BSG 2017 guidelines, perform biliary sphincterotomy and endoscopic stone extraction within 72 hours of presentation in patients with pancreatitis of suspected or proven biliary origin with associated cholangitis or persistent biliary obstruction. A Show 3 more Patients with Mirizzi syndrome: consider offering peroral cholangioscopic therapy as an alternative to surgical management in patients with Mirizzi syndrome; however, perform gallbladder resection regardless of strategy. E Patients with hepatolithiasis: consider offering a multidisciplinary approach including endoscopy, interventional radiology, and surgery in patients with hepatolithiasis. E Patients with reconstructed digestive tracts: As per BSG 2017 guidelines, consider performing ERCP for common bile duct stone extraction in patients with Billroth II anatomy. Use a forward-viewing endoscope if ERCP with a duodenoscope is difficult. C Show 2 more https://web.pathway.md/diseases/rec8FeF0Sk5yiG3JR 7/10 6/29/23, 3:51 AM Choledocholithiasis Pathway As per ASGE 2011 guidelines, consider referring patients with Billroth II or Roux-en-Y reconstructions to biliary centers of excellence, given the increased rate of complications and lower success rate of endoscopic management of common bile duct stones in these patients. C 8. Follow-up and surveillance Management of recurrent stones: manage recurrent common bile duct stones with repeat ERCP. B Clinical findings Symptoms Past medical history Abdominal pain Acute cholangitis Dark urine Acute cholecystitis Fever Acute pancreatitis Generalized pruritus Crohn's disease Loss of appetite Gallstones Nausea Hypercholesterolemia Pale stools Liver cirrhosis RUQ pain Obesity Vomiting Rapid weight loss Integument exam Lab findings Jaundice Prolonged serum PT INR Imaging findings serum ALP serum ALT Dilated bile ducts serum AST Dilated common bile duct serum TBIL Stone in the common bile duct serum gamma- glutamyltransferase serum triglycerides Likelihood Ratios Pertinent positives The following findings increase the probability of choledocholithiasis in adults. 10 Finding LR+ Value Presence of dilated bile ducts 8.1 https://web.pathway.md/diseases/rec8FeF0Sk5yiG3JR 8/10 6/29/23, 3:51 AM Choledocholithiasis Pathway Abnormal dilated bile ducts or any elevated liver test 4.4 Pertinent negatives The following findings decrease the probability of choledocholithiasis in adults. 10 Finding LR- Value Normal dilated bile ducts or any elevated liver test 0.1 Absence of dilated bile ducts 0.1 References 1. 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