eMedicine Specialties > Gastroenterology > Biliary

Choledocholithiasis: Treatment & Medication

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: Dec 15, 2009

Treatment

Medical Care

• Endoscopic retrograde cholangiopancreatography
  • ERCP is used initially as a diagnostic procedure. Once the presence of choledocholithiasis is confirmed (initial or retained stones), therapeutic options depend on the size and location of the stone(s).
  • Small stones can be retrieved with a Dormia basket or a Fogarty catheter with an intact papilla. In most situations, a sphincterotomy is needed before the stones can pass spontaneously or be extracted.
  • Stones smaller than 1 cm pass spontaneously within 48 hours. Stones that are 1-2 cm in diameter require extraction with the basket or Fogarty catheter in addition to the sphincterotomy. Stones larger than 2 cm in diameter usually require further treatment; lithotripsy or chemical dissolution (cholesterol stones) with monooctanoin acid via a nasobiliary tube has been considered. If stone extraction is unsuccessful, a biliary drainage procedure, whether internal or external, is performed.
  • The success rate of stone extraction by ERCP in cases of choledocholithiasis is 85-90% in experienced hands. Complications of sphincterotomy and stone extraction occur in 10% of cases. These include bleeding (2%), duodenal perforation (1%), cholangitis (2%), pancreatitis (2%), bile duct injury (<1%), and the usual complications associated with upper GI endoscopy (2%). The mortality rate following EST is 1%. EST is contraindicated in patients with uncorrected coagulopathy.
• Percutaneous extraction
  • This is performed after diagnostic PTC findings have confirmed the presence of CBD stones. An external biliary catheter is placed, and the tract is dilated over several weeks (2-6 wk) up to 16F size by placement of progressively larger catheters. The CBD stones are then extracted using a Dormia basket or a choledochoscope. Stones or their fragments can be trapped inside a basket and passed through the sphincter of Oddi into the duodenum. The procedure may need to be repeated for complete clearance.
  • The morbidity rate is approximately 10%, and the mortality rate is 1%. Complications include bleeding, duct injury, bile leakage, and cholangitis. The success rate is 75-85%. The procedure is contraindicated in patients with coagulopathy.
• Extracorporeal shock wave lithotripsy
  • This procedure has been mainly used as an adjunct to sphincterotomy and a percutaneous approach.
  • It carries a high rate of failure (95%) when used alone and has a high complication rate (19%). Complications include biliary pain (13%), cholangitis (5%), hemobilia (5%), ileus (2.5%), and complications related to procedure itself (13%).

Surgical Care

Surgical treatment may be required for CBD stones that are discovered preoperatively or intraoperatively. Retained stones in the CBD postoperatively are usually dealt with endoscopically or by interventional radiology. If both methods fail, operative management is contemplated. Two issues must be addressed in the surgical treatment of choledocholithiasis, as follows: (1) the exploration of the CBD, and (2) the fate of the gallbladder. Exploration of the CBD should include clearance of the stones and, sometimes, a drainage procedure. Surgical methods used to achieve this goal vary and can be performed by an open or laparoscopic route. The timing and necessity of a cholecystectomy in patients with choledocholithiasis who have asymptomatic gallbladder stones remains a subject of debate.

• Open choledochotomy
  • Traditionally, open choledochotomy has been the standard of care for the treatment of choledocholithiasis. It remains a viable option in situations in which laparoscopy is contraindicated or when laparoscopy has failed. Although this procedure carries a low morbidity and mortality rate in young patients (<1%), the mortality rate is as high as 4% in elderly populations. Moreover, it is associated with greater postoperative pain and discomfort, and a more prolonged recovery period is needed compared to the laparoscopic or endoscopic methods.
  • Choledochotomy is performed by placing 2 traction sutures on either side of the intended choledochotomy incision on the CBD distal to the cystic duct. The anterior wall of the CBD is opened longitudinally for a distance of approximately 1-1.5 cm, while traction is applied to the sutures. Stone forceps, scoops, Fogarty balloon catheters, and irrigating catheters can be used for the removal of stones. A choledochoscope can be used for confirming that the CBD is clear and for removing any retained stones. A Dormia basket can be helpful at this point.
  • Once the CBD is cleared, it is closed over a 16F T-tube using 4-0 monofilament absorbable suture. A closed suction drain is placed in the foramen of Winslow in anticipation of any bile leakage. A T-tube cholangiogram is performed 10-14 days postoperatively, and the T-tube is removed if no retained stones are seen.
  • A small-caliber duct (<6 mm in diameter) is a relative contraindication to choledochotomy.
• Transcystic exploration
  • This technique is used to clear the CBD of stones during laparoscopic cholecystectomy, after choledocholithiasis is confirmed based on findings from IOC. The cystic duct is dissected close to its junction with the CBD, and a transverse incision is made in that area. A soft hydrophilic guidewire is passed into the CBD through the cholangiogram catheter under fluoroscopic guidance. Once the position of the wire in the CBD is confirmed, the cholangiogram catheter is advanced into the CBD.
  • Isotonic sodium chloride solution is used to irrigate the CBD in an attempt to flush small stones through the sphincter of Oddi or out through the opening in the cystic duct. For extraction of larger stones, a Dormia basket is passed over the guidewire into the CBD under fluoroscopic guidance.
  • Throughout the procedure, constant flushing with isotonic sodium chloride solution is performed. At the end of the procedure, IOC is repeated to ensure that all the stones have been removed.
  • If the cystic duct is large enough or can be balloon-dilated, a flexible choledochoscope can be passed and the CBD examined under direct vision. The CBD is kept inflated with isotonic sodium chloride solution for better visualization. Intraluminal stones can be extracted with a basket under direct vision using the working port of the scope.
  • In the case of large impacted stones (>8 mm), intracorporeal lithotripsy can be used. This procedure employs either pulse-dye laser or electrohydraulic pulses that cause fragmentation of the stone. The smaller fragments are treated as described in Medical Care. Clear visualization of the stone is required in order to avoid misdirecting the energy of the probe and causing CBD injury. Due to the high cost and the fact that most CBD stones can be managed successfully without the use of intracorporeal lithotripsy, few centers have gained sufficient experience with this technique.
  • Balloon dilatation of the sphincter of Oddi can be performed when all other techniques have failed to clear the stones. A risk exists for mild pancreatitis (3% in one series). This procedure should be avoided in patients with a diagnosis of biliary dyskinesia, pancreatitis, and sphincter anomalies. It is indicated in the presence of small ducts, for which the risk of CBD stricture after choledochotomy is high. In one small series of 20 patients, the success rate was 80%.
  • Antegrade sphincterotomy can be performed; the morbidity rate is low and the success rate is 100%, as reported in a series of 22 patients. The success rate for the transcystic approach is 80-95%.
• Drainage procedures (transduodenal sphincteroplasty choledochoduodenostomy, choledochojejunostomy)
  • Transduodenal sphincteroplasty entails a retrograde approach to the exploration and clearance of the CBD.
    • During open surgery and after cholecystectomy has been completed, a Fogarty balloon catheter is passed through the cystic duct into the CBD and through the sphincter of Oddi. The duodenum is then mobilized by performing the Kocher maneuver. The ampulla is identified by palpating the balloon catheter, and a small transverse duodenotomy is performed on the anterior duodenal wall just above the ampulla.
    • A sphincterotomy is performed at the 11-o'clock mark (to avoid the pancreatic duct, which is located between the 4- and 5-o'clock positions). The sphincterotomy is carried for a distance of approximately 1 cm. The edges of the incision are sutured at the beginning of the incision and at its apex using an absorbable suture. The balloon catheter is withdrawn from the cystic duct and inserted through the ampulla in a retrograde fashion to extract the stones. A choledochoscope can also be used.
    • After the duodenotomy is closed in a transverse fashion, a completion cholangiogram is performed through the cystic duct. The cystic duct stump is closed.
    • The advantages of this procedure are that (1) it avoids a choledochotomy, (2) it is good for small-caliber CBDs, and (3) it facilitates drainage. The drawbacks are that it requires open surgery and opening of the duodenum. The success rate in an earlier series was reported as 90-100%, with morbidity and mortality rates slightly better than that with open choledochotomy. No biliary strictures were reported.
    • Approximately 30% of all patients requiring an open choledochotomy need a drainage procedure. Indications for a drainage procedure are multiple CBD stones (>4), sphincter of Oddi stenosis or dysfunction, primary CBD stones, previous choledocholithotomy, and marked CBD dilatation.
  • Choledochoduodenostomy is the most commonly employed drainage procedure and can be performed either side-to-side or end-to-side. In the side-to-side procedure, sump syndrome is a feared complication, in which food particles reflux into the CBD, resulting in obstruction, cholangitis, and/or pancreatitis. This complication can be diminished if the size of the anastomosis is limited to 14 mm.
  • Choledochojejunostomy is performed either in continuity or preferably as a Roux-en-Y loop that is passed in a retrocolic fashion. The preferred anastomotic size is 2.5 cm. It has the disadvantage of an added anastomotic line, but an advantage is that it is not associated with reflux of food particles.
• Cholecystectomy
  • Performance of a cholecystectomy in patients with choledocholithiasis remains controversial, although most experts recommend it. However, in patients who cannot tolerate surgery well (eg, due to age, medical problems), leaving the gallbladder in situ is an option as long as the organ is asymptomatic.
  • Cholecystectomy is not indicated for primary CBD stones.

Consultations

• Obviously, the gastroenterologist/endoscopist and the general/laparoscopic surgeon are the key players.
• An interventional radiologist is needed for both diagnosis and treatment at times, and the services of an infectious disease specialist are required in patients with cholangitis.
• In case lithotripsy is considered, the services of a clinician with experience in this rarely performed procedure are necessary.

Diet

Patients with choledocholithiasis are instructed to not take anything by mouth on the day of the procedures. No special diet is required either before or after the procedure.

Medication

Medications are used as an adjunct in the management of choledocholithiasis. See In/Out Patient Meds.

Antibiotics

Need for prophylaxis and therapy depends on the patient's clinical presentation.

Piperacillin (Pipracil)

Inhibits biosynthesis of cell wall mucopeptides and is effective during the stage of active multiplication. Has antipseudomonal activity.

Piperacillin and tazobactam (Zosyn)

Antipseudomonal penicillin plus beta-lactamase inhibitor. Inhibits biosynthesis of cell wall mucopeptide and is effective during the stage of active multiplication.

Mezlocillin (Mezlin)

Interferes with bacterial cell wall synthesis during the growth phase. Has antipseudomonal activity.

Ceftriaxone (Rocephin)

Third-generation cephalosporin with broad-spectrum gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin-binding proteins.

Ampicillin and sulbactam (Unasyn)

Drug combination of beta-lactamase inhibitor with ampicillin. Covers skin, enteric flora, and anaerobes. Not ideal for nosocomial pathogens.

Gentamicin (Garamycin, Gentacidin)

Aminoglycoside antibiotic for gram-negative coverage. Used in combination with both an agent against gram-positive organisms and one that covers anaerobes. Not the DOC. Consider if penicillins or other less toxic drugs are contraindicated, when clinically indicated, and in mixed infections caused by susceptible staphylococci and gram-negative organisms. Dosing regimens are numerous; adjust dose based on CrCl and changes in volume of distribution. May be given IV/IM.

Metronidazole (Flagyl)

Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Used in combination with other antimicrobial agents (except for Clostridium difficile enterocolitis).

Gastrointestinal agents

Used for stress ulcer prophylaxis.

Sucralfate (Carafate)

Forms a viscous adhesive substance that protects the GI lining against pepsin, acid, and bile salts. Use for short-term management of ulcers.

Histamine-2 receptor antagonists

Reversible competitive blockers of H2 receptors, particularly those in the gastric parietal cells, where they inhibit acid secretion. H2 antagonists are highly selective, do not affect H1 receptors, and are not anticholinergic agents.

Ranitidine (Zantac)

Inhibits histamine stimulation of the H2 receptor in gastric parietal cells, which, in turn, reduces gastric acid secretion, gastric volume, and hydrogen ion concentrations.

Famotidine (Pepcid)

Inhibits histamine stimulation of the H2 receptor in gastric parietal cells, which, in turn, reduces gastric acid secretion, gastric volume, and hydrogen ion concentrations.

Anticoagulants

Used for DVT prophylaxis.

Heparin

Augments activity of antithrombin III and prevents conversion of fibrinogen to fibrin. Does not actively lyse but is able to inhibit further thrombogenesis. Prevents reaccumulation of clot after spontaneous fibrinolysis.

Enoxaparin (Lovenox)

Prevents DVT, which may lead to pulmonary embolism in patients undergoing surgery who are at risk for thromboembolic complications. Enhances inhibition of factor Xa and thrombin by increasing antithrombin III activity. In addition, preferentially increases inhibition of factor Xa. Average duration of treatment is 7-14 d.

Proton pump inhibitors

Indicated for peptic ulcer disease. Indicated for prophylaxis against stress ulcerations in setting of choledocholithiasis. Should be reserved for patients with known peptic ulcer disease.

Omeprazole (Prilosec)

Description Decreases gastric acid secretion by inhibiting parietal cell H⁺/K⁺ -ATP pump.

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