eMedicine Specialties > Gastroenterology > Biliary

Choledocholithiasis: Follow-up

Author: Imad S Dandan, MD, Consulting Surgeon, Department of Surgery, Trauma Section, Scripps Memorial Hospital
Coauthor(s): Assaad M Soweid, MD, Assistant Professor, Department of Internal Medicine, American University of Beirut, Lebanon; Firass Abiad, MD, Head of Division, General and Laparoscopic Surgery, Specialized Medical Center Hospital, Saudi Arabia
Contributor Information and Disclosures

Updated: Jul 16, 2008

Follow-up

Further Inpatient Care

  • Tube cholangiography: Whenever a tube or biliary drain is placed (eg, surgically, percutaneously, or radiologically), a follow-up cholangiogram through the tube is recommended. A tube cholangiogram helps assess for the presence of retained stones, the status of the sphincter of Oddi, the architecture of the biliary tree, and the condition of the anastomosis. This study is best performed under fluoroscopic guidance in the radiology department.
  • Laboratory data: Serum bilirubin levels and liver enzymes are measured in the postprocedure period as part of follow-up care.

Further Outpatient Care

  • Laboratory data: Serum bilirubin levels and liver enzymes are measured in the postprocedure period as follow-up care.
  • Management of retained stones: Extraction (or consideration of lithotripsy) of retained stones is performed 6 weeks after placement of a biliary drain or catheter, when the tract is mature. Dissolution of the stones using monooctanoin is another option.

Inpatient & Outpatient Medications

  • Antibiotics
    • Antibiotics are needed for prophylaxis or for acute infection, depending on the patient's presentation. In the absence of biliary infection and in the setting of a procedure that results in manipulation of the biliary tree, antibiotic prophylaxis may be indicated. Single-drug therapy with a broad-spectrum antibiotic is preferable. The newer penicillins (piperacillin, mezlocillin), with or without beta-lactamase inhibitor, are effective because of their broad coverage. This is also true of some of the third-generation cephalosporins.
    • Administer the antibiotics intravenously immediately before the procedure and discontinue them at the end of the procedure, unless a prosthesis or a drain is inserted. In the setting of cholangitis, antibiotics are used therapeutically. Traditionally, ampicillin was used in combination with an aminoglycoside and metronidazole as a broad-spectrum regimen for empirical treatment until specific culture and sensitivity results were obtained. However, as mentioned above, the broad-spectrum newer penicillins or third-generation cephalosporins, with or without beta-lactamase inhibitors, are good choices. Antibiotics are customized after obtaining culture results. In mild cases, antibiotics can be administered at home either orally or intravenously.
  • Stress ulcer prophylaxis: This is achieved by using sucralfate, H2 antagonists, or proton pump inhibitors.
  • Deep venous thrombosis prophylaxis: A mini dose of heparin (5000 U SC q12h) or low molecular weight heparin can be used in conjunction with sequential compression pneumatic stockings. Early ambulation remains the best preventative approach.

Transfer

  • The patient should be transferred to a center capable of handling this problem. Specialists in the fields mentioned in Consultations should be available, and the center should be equipped with the diagnostic and therapeutic modalities necessary for the job at hand.

Complications

Prognosis

  • Prognosis of choledocholithiasis depends on the presence and severity of complications. Of all patients who refuse surgery or are unfit to undergo surgery, 45% remain asymptomatic from choledocholithiasis, while 55% experience varying degrees of complications.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Medicolegal concerns in the management of choledocholithiasis are multifaceted. They relate to the diagnosis, management, and follow-up because of the complexity of the issue. Maintaining the standard of care and obtaining the appropriate consultations help mitigate medicolegal concerns.
 


More on Choledocholithiasis

Overview: Choledocholithiasis
Differential Diagnoses & Workup: Choledocholithiasis
Treatment & Medication: Choledocholithiasis
Follow-up: Choledocholithiasis
Multimedia: Choledocholithiasis
References
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Further Reading

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Keywords

common bile duct stones, CBD stones, cholelithiasis, cholecystectomy, gallstones, gallbladder stones, Ascaris lumbricoides, A lumbricoides, Clonorchis sinensis, C sinensis, gallstone disease, cholesterol stones, black pigment stones, brown pigment stones, jaundice, cholangitis, pancreatitis, sepsis, parasitic infestation, bile stasis, chronic bactibilia

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Contributor Information and Disclosures

Author

Imad S Dandan, MD, Consulting Surgeon, Department of Surgery, Trauma Section, Scripps Memorial Hospital
Imad S Dandan, MD is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Surgeons, American Medical Association, American Trauma Society, California Medical Association, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Assaad M Soweid, MD, Assistant Professor, Department of Internal Medicine, American University of Beirut, Lebanon
Assaad M Soweid, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Gynecological and Obstetrical Society, and American Medical Association
Disclosure: Nothing to disclose.

Firass Abiad, MD, Head of Division, General and Laparoscopic Surgery, Specialized Medical Center Hospital, Saudi Arabia
Disclosure: Nothing to disclose.

Medical Editor

David Greenwald, MD, Fellowship Program Director, Associate Professor, Department of Medicine, Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine
David Greenwald, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

BS Anand, MD, Department of Internal Medicine, Division of Gastroenterology, Professor, Baylor University College of Medicine
BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Assistant Dean for Medical Curriculum, Associate Professor of Medicine, Division of General Internal Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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