Choledocholithiasis is the presence of stones in the common bile duct (CBD). This occurs when gallstones become obstructed when passing through the CBD, resulting in an obstructive jaundice, right upper quadrant pain, and transaminase elevation, and places patients at risk for cholangitis and cholecystitis.

Gallstones are very common in the United States, present in about 15% of the overall population (most common in middle-aged women and linked to obesity). However, most patients with gallstones are asymptomatic. About 15%-26% of people with gallstones will develop symptoms of biliary colic (crampy, waxing / waning right-sided abdominal pain) over a 10-year period, and of those, an estimated 10%-20% will develop CBD stones with risk of obstructing and developing choledocholithiasis.

Choledocholithiasis can be caused either by secondary stones, which are gallstones that reside in the gallbladder and become obstructed when passing through the cystic and common bile duct, or primary stone formation that occurs in the CBD itself. Secondary stones leading to choledocholithiasis are a significantly more common etiology, although de novo primary stones are seen in patients post-cholecystectomy and seem to have a slightly increased prevalence in Southeast Asia.

Suspect choledocholithiasis in patients with prolonged right upper quadrant or epigastric pain (>6 hours), nausea, vomiting, and associated liver function test abnormalities (primarily elevated aspartate transaminase [AST] / alanine transaminase [ALT], alkaline phosphatase, and direct bilirubin). Fever is not usually associated with uncomplicated choledocholithiasis.

Complications include acute cholangitis characterized by fever, right upper quadrant pain, jaundice, and sometimes altered mental status with hypotension. Acute pancreatitis may also occur, manifested by nausea, vomiting, elevated lipase, with imaging suggestive of acute pancreatitis (often CT or MRI / magnetic resonance cholangiopancreatography [MRCP]).

Once a patient has developed choledocholithiasis, they are at increased risk of recurrence of an obstructing stone, often within 6-18 weeks. It is strongly recommended that these patients undergo cholecystectomy following decompression of the biliary tree. Often, an endoscopic retrograde cholangiopancreatography (ERCP) with balloon dilation or sphincterotomy is done to relieve obstruction due to choledocholithiasis, which, in patients who are post-cholecystectomy at the time of developing choledocholithiasis, can help with the passage of future stones. In some instances, biliary stenting needs to be considered.

Symptoms typically improve drastically following decompression of the obstructed CBD, often within 24 hours if not immediately following ERCP or the spontaneous passage of an obstructed stone.