Choledocholithiasis

Overview

What is choledocholithiasis?

Choledocholithiasis is the condition of having a gallstone (or stones) in your common bile duct. “Choledocho” is the Latin term for the common bile duct, and “lithiasis” means stones. Gallstones are pebble-like pieces of concentrated bile materials. They can develop in any place bile flows through.

What is choledocholithiasis vs. cholelithiasis?

You may have also heard the term “cholelithiasis,” which is similar. Cholelithiasis is the condition of having gallstones in your gallbladder. Gallstones may develop in your gallbladder or bile ducts, or both. A gallstone that develops in your gallbladder may also travel to your common bile duct.

What is choledocholithiasis vs. biliary colic?

If you have choledocholithiasis, you have at least one gallstone in your common bile duct. If it’s very small, it may not cause you any problems and may even pass into your intestines. But if it becomes large enough or blocks your common bile duct, it’ll cause symptoms of severe constant pain and jaundice.

Biliary colic is intermittent pain from gallstones that obstruct your biliary system intermittently (off and on). This is more common with gallbladder stones, but can happen with choledocholithiasis if a gallstone obstructs your common bile duct off and on — for example, if it moves in and out of your duct.

Is choledocholithiasis an emergency?

A gallstone, or several, in your common bile duct isn’t necessarily an emergency, but it’s a risk. Smaller gallstones may pass safely through your common bile duct to your intestines and out of your body. The risk is that they’ll become stuck there and grow large enough over time to cause a blockage.

Because of this risk, healthcare providers prefer to treat common bile duct stones immediately when they find them. They’ll recommend an endoscopic procedure to examine and, most likely, remove the stones. That means a gastroenterologist will access your bile ducts via a catheter passed down your throat.

What can choledocholithiasis lead to?

If a gallstone stays in your common bile duct and grows large enough to block the flow of bile through the duct, it endangers your entire biliary system. That’s the network of organs and vessels that bile travels through. A blockage can cause inflammation, infection and life-threatening complications.

How common is choledocholithiasis?

About 10% of people have gallstones, but most of them form in their gallbladder. About 15% of people with gallstones have them in their common bile duct. Gallstones will never bother most people. Only 20% of people with gallstones will have complications that require treatment.

Symptoms and Causes

What are the symptoms of choledocholithiasis?

You may not have any symptoms. Unless your gallstones cause a blockage, you may never even know they’re there. If you do have symptoms, it means that a stone is blocking your common bile duct. The first sign of a blockage will be the symptoms of biliary colic. These can include:

  • Abdominal pain. Biliary pain occurs in episodes lasting from one to several hours, usually after a meal. It grows for the first 20 minutes and gradually declines after that. Most people feel it in their upper right abdomen, but it may also radiate to your right side or shoulder blade.
  • Nausea and vomiting. Biliary colic is often accompanied by nausea and vomiting. You’ll notice that vomiting doesn’t relieve the pain, as it does with some other types, like migraines. If biliary colic isn’t as intense, you may only notice a general lack of appetite.
  • Jaundice. When bile backs up and leaks into your bloodstream, it may show up as a yellow tint to your skin or the whites of your eyes. It may also turn your pee a darker color. Jaundice can come and go, like biliary colic. But it’ll keep coming back until the blockage is cleared.
  • Fever. Severe inflammation in your biliary system may cause a fever. Fever may also be a sign of an infection. When your bile ducts are blocked, bacteria aren’t flushed out as usual.

What are the possible complications of choledocholithiasis?

A gallstone that blocks your common bile duct will cause bile to back up behind the blockage. This can affect all of your ducts and organs connected to it, including your gallbladder, pancreas and liver. It causes inflammation, breeds infection and can lead to long-term tissue damage. Complications include:

  • Infection. A blocked bile duct is an easy breeding ground for bacterial infections. An infection in your biliary system is very dangerous. It can spread to your liver and your bloodstream. An infection in your bloodstream (septicemia) can lead to life-threatening complications (sepsis).
  • Cholangitis. Choledocholithiasis is the most common cause of cholangitis, inflammation and infection of your common bile duct. Backed-up bile causes your bile duct to swell, which further slows the flow of bile. Inflammation and infection can spread from your common bile duct to its branches, including those that run through your liver. It can cause your liver to swell.
  • Cholecystitis. Cholecystitis is inflammation in your gallbladder. Bile backing up into your gallbladder will cause it to swell. This is painful and can stop it from functioning well and eventually damages the organ. This is the most common cause of gallbladder disease.
  • Gallstone pancreatitis. Your bile ducts share the same exit channel into your intestines as your pancreas. Gallstones that block this common channel can also block secretions from your pancreas. These secretions, which contain very potent enzymes, will back up into your pancreas and cause severe inflammation and organ damage called pancreatitis. Gallstones obstructing your bile ducts is the most common cause of nonalcohol-related pancreatitis.

What causes choledocholithiasis?

Your liver makes bile out of materials it filters from your blood. These materials include cholesterol, bilirubin, bile salts and lecithin. Gallstones occur when there’s too much of one of these — usually cholesterol, but sometimes bilirubin — and the excess materials turn into a kind of sediment.

The sediment collects at the bottom of your gallbladder or your common bile duct and eventually hardens. The stones gradually grow as sediment continues to wash over them. This takes many years. Most gallstones form in your gallbladder and travel with the flow of bile into your common bile duct.

What risk factors are associated with choledocholithiasis?

You may be more likely to get a gallstone in your common bile duct if you:

  • Have chronic cholangitis. Choledocholithiasis is a major cause of cholangitis, but it can also work the other way around. If you have inflammation in your bile ducts from another cause, it may cause bile to slow and stall in your bile ducts, leading to sedimentation and gallstones.
  • Have had gallstones before. Most people with gallstones don’t have complications, but people who’ve had them before are more likely to have them again. Even if you’ve had your gallbladder removed to treat gallstones, rarely, you may still develop new stones in your bile ducts.

You may be more likely to have gallstones in general if you:

  • Have high cholesterol. Most (75% of) gallstones are formed from excess cholesterol in your blood. Other bile ingredients (bile salts and lecithin) are supposed to help emulsify the cholesterol, but if there’s an imbalance between them, this doesn’t work.
  • Have female hormones. Estrogen increases cholesterol, and progesterone slows gallbladder contractions, which increases sedimentation. Both hormones are higher during certain periods in female reproductive life, and hormone replacement therapy can also elevate them.

Diagnosis and Tests

How is choledocholithiasis diagnosed?

Gallstones in your bile duct usually aren’t discovered unless they cause symptoms. If you seek healthcare for symptoms of biliary colic or jaundice, your healthcare provider will investigate with blood tests and imaging tests. Blood tests will show the buildup of bile, and imaging will find the blockage.

What tests are used to diagnose choledocholithiasis?

Blood tests may include:

Imaging tests may include:

  • Abdominal ultrasound. An ultrasound is a simple and noninvasive test that can give some early clues about your condition. It can reveal gallstones in your gallbladder, if there are any. It doesn’t visualize the common bile duct as well, but it can show if your duct is dilated, which indicates a blockage. It may also show shadowing where the blockage is.
  • Endoscopic ultrasound This test combines ultrasound technology with an upper endoscopy exam for a clearer picture of your bile ducts. It involves passing a tiny lighted camera on a tube (endoscope) down your throat and into your upper gastrointestinal (GI) tract. An ultrasound probe on the end of the endoscope sends out sound waves to produce images of your biliary system.
  • MRCP. Magnetic resonance cholangiopancreatography (MRCP) is a type of MRI that specifically visualizes the bile ducts. It’s noninvasive and creates very clear images of your biliary system, including the common bile duct. Your provider might use this test first to find a suspected gallstone there. But if they’re already pretty sure it’s there, they might go straight to an ERCP.
  • ERCP. ERCP stands for endoscopic retrograde cholangiopancreatography. This test is a little more invasive, but it’s a useful one for finding gallstones because it can also be used to remove them. It combines X-rays and endoscopy. When the endoscope reaches the top of your small intestine, your technician slides another, smaller tube into the first one to reach farther down into your bile ducts. They inject a special dye through the tube and then take video X-rays (fluoroscopy) as the dye travels through your ducts. When they find stones, they can treat them.

Management and Treatment

How do doctors remove gallstones in the common bile duct?

They usually remove them during an ERCP exam. Doctors can attach special tools to the endoscope to break up and remove the stones when they find them. Sometimes, they make a surgical cut into the muscle of the duct to open it up and allow stones to pass. This is called a sphincterotomy.

Does choledocholithiasis require surgery?

The endoscopic procedure (ERCP) doesn’t require cutting into your abdomen to access the bile ducts. However, after removing gallstones from your bile ducts, doctors often recommend surgery to remove your gallbladder. This is to prevent more gallstones from exiting your gallbladder and causing choledocholithiasis again.

Will I need any other treatments?

Depending on your condition, you may need treatment before your gallstones can be removed, such as:

What are the complications of the treatment?

Short-term complications of endoscopic gallstone removal may include:

  • Bleeding.
  • Infection.
  • Pancreatitis.

Long-term complications after treatment may include:

  • Gallstone recurrence. Even after removing all the gallstones in your bile ducts, it’s possible for new ones to form there later on. People who have had them are more likely to get them again.
  • Bile duct fibrosis. Cutting into your bile duct can cause scarring of the tissue, and sometimes, scar tissue causes the passageway to narrow (biliary stricture). This can cause a different kind of obstruction in the common bile duct. It may require another procedure to treat it.

Prevention

Can choledocholithiasis be prevented?

As cholesterol gallstones are the most common type, you may be able to reduce your risk by reducing cholesterol in your blood through dietary and lifestyle changes. Healthcare providers also recommend that you avoid “yo-yo” dieting and lose weight gradually. Losing too quickly can encourage gallstones.

Outlook / Prognosis

What is the prognosis after treatment for choledocholithiasis?

Treatment is simple and effective for most people. If you’re among the few who have complications afterward, these complications are also treatable. Between 5% and 25% of people may develop new gallstones in their bile ducts within 10 to 20 years. The risk is less if you have your gallbladder removed.

A note from Cleveland Clinic

A gallstone attack can be intense and scary, especially if you didn’t know you had gallstones. The sooner you seek treatment, the sooner you’ll find relief. Always take biliary colic seriously, even if it goes away or isn’t yet severe. An obstruction in your bile duct will only get worse until it’s removed.

Last reviewed by a Cleveland Clinic medical professional on 09/19/2022.

References

  • Osmosis. Choledocholithiasis: What Is It, Causes, Diagnosis, Treatment, and More. (https://www.osmosis.org/answers/choledocholithiasis) Accessed 9/19/2022.
  • Medline Plus. Choledocholithiasis. (https://medlineplus.gov/ency/article/000274.htm) Accessed 9/19/2022.
  • Merck Manual Professional Version. Choledocholithiasis and Cholangitis. (https://www.merckmanuals.com/professional/hepatic-and-biliary-disorders/gallbladder-and-bile-duct-disorders/choledocholithiasis-and-cholangitis) Accessed 9/19/2022.

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