Choledocholithiasis Management Antibiotic prophylaxis Q Does the patient have concomitant cholangitis? Q Is the immunosuppressed? Q Is biliary drainage predicted to be incomplete? Yes to any Consider initiating antibiotics in patients with acute cholangitis, immunosuppression, or when biliary drainage is predicted to be incomplete. C No to all Avoid routine antibiotics unless cholangitis is present, biliary drainage is predicted to be incomplete, or the patient is immunosuppressed. D Stone removal ASGE Q Does the patient have confirmed common bile duct stones? Yes Remove common bile duct stones when detected unless significant mitigating clinical circumstances are present. B No Continue management and follow-up as clinically appropriate. Patients with reconstructed digestive tracts ASGE Q Does the patient have a past history of Billroth II or Roux-en-Y surgery? Yes 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 No Laparascopic common bile duct exploration ASGE Q Does the patient have symptomatic cholelithiasis? Yes 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 No Biliary stenting ASGE Q Does the patient have common bile duct stones that are refractory to initial endoscopic extraction? Yes 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 Endoscopic papillary balloon dilation ASGE Q Does the patient have large, difficult to remove common bile duct stones? Yes 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 No Cholecystectomy ASGE Q Has the patient undergone preoperative ERCP for choledocholithiasis? Yes Consider performing cholecystectomy without intraoperative cholangiogram in patients with symptomatic cholelithiasis without risk factors. E No Management of recurrent stones Q Does the patient have recurrent common bile duct stones? Yes Manage recurrent common bile duct stones with repeat ERCP. B No Biliary stenting ASGE Q Has complete stone extraction been achieved? Q Does the patient have severe acute cholangitis? Place a plastic biliary endoprosthesis to ensure adequate drainage in cases of incomplete stone extraction or severe acute cholangitis. B