Choledocholithiasis

Common bile duct stone causing biliary obstruction — may be asymptomatic or present with colic, jaundice, or cholangitis

Symptoms / Associated Sx

  • RUQ or epigastric pain (colicky, postprandial)

  • Jaundice, dark urine, pale stools (biliary obstruction)

  • Pruritus (conjugated hyperbilirubinemia)

  • Fever if secondary cholangitis develops

Denies

  • High fever + rigors + hypotension (rules out cholangitis if absent — lower urgency for ERCP)

  • Weight loss, anorexia (rules out malignant biliary obstruction if absent)

  • Pain radiating to right shoulder (reduces isolated CBD stone likelihood)

Social History (SHx)

Known gallstones, prior cholecystectomy (retained/recurrent CBD stone), obesity, female, age >40, rapid weight loss, prior biliary surgery or ERCP.

Main Etiology

  • Secondary CBD stones (migrated from gallbladder — most common)

  • Primary CBD stones (de novo in duct); recurrent post-cholecystectomy

  • Bile duct stricture → bile stasis → stone formation

Most Common DDx

  • Acute cholangitis (CBD stone + infection → Charcot's triad; fever + jaundice + RUQ pain; WBC elevated; CBD dilation; ERCP is urgent)

  • Acute cholecystitis (cystic duct obstruction — RUQ pain + fever + positive Murphy's; bilirubin/ALP may be mildly elevated but CBD not dilated; wall thickening on US)

  • Malignant biliary obstruction — pancreatic head cancer or cholangiocarcinoma (painless jaundice + weight loss; progressive; CBD dilation with mass on CT/MRCP; no stones)

  • Primary sclerosing cholangitis (PSC) (strictures without stone; young male with IBD; beaded/pruned-tree appearance on MRCP; ALP >> bilirubin)

  • Acute pancreatitis with biliary etiology (ALT >3× ULN; lipase >3× ULN; CBD stone often present; overlapping presentation)

  • Mirizzi syndrome (external CBD compression by gallstone in cystic duct/Hartmann's pouch — appears like CBD obstruction but stone is extrinsic; CT/MRCP distinguishes)

DATA

  • LFTs (elevated ALP, GGT, bilirubin — cholestatic pattern); CBC (WBC if cholangitis); lipase, amylase (if pancreatitis)

  • PT/INR; BMP (renal function)

  • RUQ ultrasound (CBD dilation >6–8 mm + gallstones); MRCP (first-line for suspected CBD stone); EUS; ERCP (therapeutic)

Home Meds

  • Anticoagulants (hold before ERCP; INR <1.5 for procedure)

  • Antiplatelets (hold 5–7 days before ERCP)

Plan

  • NPO; IV fluids; pain management (ketorolac, opioids PRN)

  • ERCP with sphincterotomy and stone extraction:

    • Urgent (<24h): concurrent cholangitis or severe pancreatitis

    • Elective (24–72h): uncomplicated choledocholithiasis

  • Indomethacin 100 mg PR immediately after ERCP (reduces post-ERCP pancreatitis risk ~50%)

  • Antibiotics if cholangitis suspected (see cholangitis section)

  • Cholecystectomy: same hospitalization or within 2–4 weeks after ERCP and stone clearance

  • Monitor LFTs/bilirubin post-ERCP; trend CBC, BMP daily; GI/surgery consult; PT/OT if prolonged

  • Discharge: Low-fat diet; surgery follow-up for cholecystectomy within 2–4 weeks; LFTs recheck in 2 weeks; return precautions: fever, recurrent jaundice, severe RUQ pain

Red Flags

  • Charcot's triad (fever + jaundice + RUQ pain) → cholangitis → urgent antibiotics + ERCP within 24h

  • Reynolds' pentad (+ hypotension + AMS) → severe cholangitis → ICU + emergent ERCP

  • Post-ERCP fever or rising bilirubin → retained stone or cholangitis → repeat imaging + ERCP

  • Rising lipase post-ERCP → post-ERCP pancreatitis → aggressive IVF, analgesia

  • Painless jaundice + weight loss without stone → malignant obstruction → CT/MRCP urgently

Senior IM Resident Pearls

  • ASGE high-probability criteria (any one): bilirubin >4, CBD stone on US, clinical cholangitis → proceed directly to ERCP; intermediate → MRCP or EUS first

  • Indomethacin 100 mg PR post-ERCP — guideline-recommended; reduces post-ERCP pancreatitis by ~50%

  • MRCP sensitivity ~90–95% for CBD stones — excellent non-invasive first step for intermediate probability

  • Common mistake: Skipping cholecystectomy after ERCP — recurrence rate 10–15%/year without it

ORDERS

Labs

Admission Labs

  • CBC with diff

  • CMP

  • BMP

  • LFTs (AST, ALT, ALP, GGT, total/direct bilirubin)

  • PT/INR

  • PTT

  • Lipase

  • Amylase

  • Magnesium

  • Phosphorus

Additional Labs

  • Blood cultures ×2 (if fever/cholangitis concern)

  • Lactate (if sepsis concern)

  • Type & Screen if unstable

  • CA 19-9 (only if malignancy becomes concern)

Trending Labs

  • CBC daily

  • CMP daily

  • LFTs daily

  • BMP daily

  • Lipase daily if pancreatitis

  • Bilirubin trend after ERCP

Imaging

First-Line

RUQ Ultrasound

Evaluate:

  • Gallstones

  • CBD dilation (>6–8 mm)

  • Cholecystitis

  • Biliary obstruction

Second-Line

MRCP

Preferred diagnostic study if:

  • Intermediate probability

  • Stable patient

  • Unclear diagnosis

Alternative

EUS

If MRCP unavailable or high suspicion

If Malignancy Concern

CT Abdomen/Pelvis with Contrast

Evaluate:

  • Pancreatic cancer

  • Cholangiocarcinoma

  • Mass lesion

Procedures

ERCP (Definitive Therapy)

Urgent (<24 hr)

  • Cholangitis

  • Severe gallstone pancreatitis with obstruction

Early (24–72 hr)

  • Uncomplicated choledocholithiasis

During ERCP

  • Sphincterotomy

  • Stone extraction

  • Balloon sweep

  • Stent placement if needed

Cholecystectomy

Same Admission Preferred

OR

Within 2–4 Weeks

After stone clearance

Medications

Supportive Care

NPO

  • Until ERCP completed

IV Fluids

LR Preferred

  • 100–150 mL/hr maintenance

  • Additional boluses PRN

Pain Control

First-Line

  • Ketorolac 15–30 mg IV q6h PRN

Alternative

  • Hydromorphone 0.2–0.5 mg IV q2–4h PRN

  • Oxycodone 5–10 mg PO q4–6h PRN

Antiemetics

Ondansetron

  • 4 mg IV q6h PRN

Alternative

  • Metoclopramide 10 mg IV q6h PRN

Post-ERCP Pancreatitis Prevention

Indomethacin

  • 100 mg PR immediately after ERCP

(Standard of care)

If Cholangitis Present

Ceftriaxone

  • 2 g IV daily

PLUS

Metronidazole

  • 500 mg IV q8h

OR

Piperacillin-Tazobactam

  • 4.5 g IV q6h

OR

Meropenem

  • 1 g IV q8h (ESBL risk)

Hold Medications

Before ERCP

  • Warfarin

  • DOACs

  • Heparin

  • Clopidogrel

  • Ticagrelor

Goal

  • INR <1.5

Avoid

  • Hepatotoxic medications if significant obstruction

Consults

Gastroenterology (All Patients)

  • ERCP

  • Stone extraction

General Surgery

  • Cholecystectomy planning

Interventional Radiology

If ERCP unsuccessful

Oncology

If malignancy identified

PT/OT

If prolonged hospitalization

Nursing Orders

Monitoring

  • Vital signs q4 hr

  • Strict I&O

  • Daily weights

Diet

  • NPO pending ERCP

  • Advance to low-fat diet after procedure

Notify Physician Immediately

  • Fever

  • Worsening jaundice

  • Hypotension

  • AMS

  • Increasing abdominal pain