Choledocholithiasis (Common Bile Duct Stones)

How bile duct stones form

The liver makes bile, which drains through small ducts that join to form the common bile duct. The gallbladder stores bile and squeezes it into the duct after meals. The duct then passes through the pancreas head and opens into the duodenum at the ampulla of Vater, where it joins the pancreatic duct.

• Secondary stones (most common in Western countries): form in the gallbladder (gallstones) and migrate into the bile duct.
• Primary stones: form in the bile duct itself, usually brown pigment stones related to bile stasis, infection or narrowing. They are more common in East Asia and can appear years after gallbladder removal.

When a stone blocks the duct, bile backs up into the liver and blood, causing jaundice. Stagnant bile can become infected.

Choledocholithiasis vs related terms

Symptoms

Some stones pass into the intestine on their own and cause no symptoms. When a stone blocks the duct:

• pain in the upper right or middle belly, sometimes spreading to the right shoulder blade, lasting hours
• jaundice: yellow skin and whites of the eyes
• dark urine and pale, clay-colored stools
• itching from bile salts in the skin
• nausea and vomiting
• fever and chills if infection develops

The classic triad of fever, jaundice and right upper belly pain (Charcot's triad) suggests acute cholangitis, a medical emergency.

Risk factors

• existing gallstones
• older age
• female sex, pregnancy and estrogen therapy
• obesity and rapid weight loss
• family history
• hemolytic conditions such as sickle cell disease (pigment stones)
• bile duct narrowing, previous biliary surgery, or parasites in some regions

Diagnosis

1. Blood tests: liver tests (bilirubin, alkaline phosphatase, GGT, ALT and AST) are usually raised in an obstructive pattern; lipase checks for pancreatitis; white cell count and blood cultures for infection.
2. Abdominal ultrasound: the first imaging test; shows gallbladder stones and a widened bile duct, though duct stones themselves are often hidden by bowel gas.
3. MRCP: an MRI of the bile ducts, very accurate for stones without being invasive.
4. Endoscopic ultrasound (EUS): a camera with an ultrasound tip passed into the duodenum; highly accurate, especially for small stones.
5. ERCP: both diagnoses and treats; reserved for people with a high likelihood of stones because it carries risks.

Doctors use guidelines that combine blood tests and ultrasound to estimate the likelihood of a duct stone and choose the next test.

Treatment

ERCP

Endoscopic retrograde cholangiopancreatography is the main treatment. Under sedation, a flexible scope is passed through the mouth to the duodenum. The opening of the bile duct is widened with a small cut (sphincterotomy), and stones are pulled out with a balloon or basket. Large stones can be broken with lasers or mechanical crushing. A temporary stent may be placed if stones cannot all be removed.

ERCP risks include pancreatitis (in a small percentage), bleeding, infection and, rarely, perforation.

Gallbladder removal

Because more stones are likely to form in the gallbladder and pass into the duct, guidelines recommend laparoscopic cholecystectomy, ideally during the same hospital stay or soon after ERCP. Some surgeons remove duct stones during the operation itself (laparoscopic bile duct exploration).

Cholangitis

Treatment includes IV fluids, antibiotics, and urgent drainage of the bile duct by ERCP, typically within 24 to 48 hours, or sooner if severe.

Complications

• acute cholangitis and sepsis
• gallstone pancreatitis
• liver abscess
• secondary biliary cirrhosis with long-standing blockage

Outlook

With prompt removal of stones and gallbladder surgery, most people recover fully. Recurrence of duct stones after cholecystectomy is uncommon but possible, particularly with primary pigment stones.

Frequently asked questions

What is choledocholithiasis?

Choledocholithiasis is the presence of gallstones in the common bile duct. Most stones form in the gallbladder and move into the duct, where they can block bile flow and cause pain, jaundice, infection or pancreatitis.

What are the symptoms of a bile duct stone?

Symptoms include pain in the upper right or middle belly, yellow skin and eyes, dark urine, pale stools, itching, nausea and vomiting. Fever with chills suggests infection of the bile duct and needs emergency care.

How are bile duct stones removed?

Most are removed by ERCP, in which a scope passed through the mouth reaches the bile duct opening, widens it, and pulls out the stones with a balloon or basket. Some surgeons remove them during laparoscopic gallbladder surgery.

Can a bile duct stone pass on its own?

Small stones sometimes pass into the intestine without treatment, and symptoms and blood tests then improve. Because stuck stones can cause serious infection or pancreatitis, doctors usually confirm the duct is clear and remove the gallbladder to prevent new stones.

Do I need my gallbladder removed after ERCP?

In most cases, yes. Without cholecystectomy, many people develop further gallstone problems, including new duct stones, cholecystitis or pancreatitis. Removal is often done during the same admission or within a few weeks. It may be avoided in people too frail for surgery.