Choledocholithiasis is the presence of gallstones in the main bile duct. The symptoms of choledocholithiasis can range from being completely asymptomatic to experiencing pain under the right rib cage, nausea, vomiting, fever, and jaundice, which can be accompanied by itching, dark urine, and pale stools.
In patients with symptoms suggestive of gallstones in the bile ducts, it is necessary to perform laboratory tests to check the levels of liver enzymes. An ultrasound examination can be used to confirm the presence of gallstones in the bile ducts and their dilation, which may indicate the presence of an obstruction. However, magnetic resonance cholangiopancreatography (MRCP) is the most reliable non-invasive diagnostic method for establishing a definitive diagnosis. During this procedure, a contrast agent is injected, which fills the bile ducts, gallbladder, and pancreatic ducts and enables their adequate visualization.
Endoscopic ultrasound is a highly specific diagnostic method that is indicated in patients with obstruction in the distal parts of the main bile duct of unclear etiology. This involves placing an ultrasound probe into the duodenum up to the level where the main bile duct and pancreatic duct drain. In addition to adequate visualization of this region, the advantage of this method is the possibility of taking a biopsy from the site of obstruction if it turns out that it is not caused by the presence of gallstones.
Treatment of choledocholithiasis can be carried out in several ways:
a) The most common approach initially involves removing the stones from the bile duct using a minimally invasive method called endoscopic retrograde cholangiopancreatography (ERCP). During this procedure, an endoscope is placed through the mouth, esophagus, and stomach into the duodenum. Contrast is then injected into the bile and pancreatic ducts, and a radiograph of the abdomen is taken. Papillotomy or transduodenal sphincterotomy and calculus evacuation can be performed during the procedure. Papillotomy involves cutting the muscle flap at the point where the bile and pancreatic ducts flow into the duodenum, which facilitates endoscopic extraction of gallstones from the bile duct.
b) If the ERCP procedure does not succeed in removing the gallstones, the gallbladder can be removed and the stones can be evacuated from the bile duct in the same operation by laparoscopic surgery. During this operation, the bile duct is opened, and the stones are removed using a combination of different techniques. A T-drain is placed in the bile duct’s lumen, which allows the bile to flow to the outside environment until the reconstructed incision site heals.
c) In the event that the endoscopic approach is impossible or unsuccessful, the removal of gallstones from the gallbladder and bile duct can be performed with a classic operation that involves a longer hospital stay and recovery.
A T-tube cholangiogram is a fluoroscopic procedure in which contrast medium is injected through a T-tube into the patient’s biliary tree.
In all patients with diagnosed symptomatic choledocholithiasis, ERCP with papillotomy and laparoscopic cholecystectomy is indicated.
ERCP procedures with papillotomy can rarely be complicated by the occurrence of acute pancreatitis in the early post-procedural period or bleeding from blood vessels located near the papilla’s cutting.
ERCP and laparoscopic gallbladder surgery are minimally invasive procedures that allow for a quick recovery. The average hospital stay is one day after the intervention.
