Modern Management of Common Bile Duct Stones

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Key points

  • Given lack of efficacy relative to endoscopic retrograde cholangiography (ERCP), pharmacologic therapy for bile duct stones should be reserved for patients who are not candidates for therapeutic procedures.

  • ERCP should be performed only if there is a high suspicion of bile duct stones; imaging studies for confirmation should be performed if there is intermediate suspicion, to minimize complications associated with ERCP.

  • ERCP with sphincterotomy, mechanical lithotripsy, and stent placement may be

Genesis and pharmacologic therapy for bile duct stones

Medical therapy for gallstone disease was championed particularly in the 1970s and early 1980s. Interest has waned since the introduction of laparoscopic cholecystectomy and ERCP, whereby stones in the gallbladder and bile duct may be removed with low morbidity. Medical therapy aims to correct the biochemical anomalies that cause cholesterol and pigment stone formation. More recently, there has been keen interest in addressing and treating stone disease as part of the metabolic syndrome.

Clinical approach to bile duct stones

In the contemporary era, most bile duct stones are removed by ERCP and concomitant gallbladder stones are removed by laparoscopic cholecystectomy. Although it is the least invasive approach, ERCP for the removal of bile duct stones is associated with complications in 8% to 10% of patients.25 Thus it is critical that ERCP be used only for therapy and not diagnosis, which necessitates accurately assessing probability of bile duct stones.

Endoscopic removal of bile duct stones

In the era of laparoscopic cholecystectomy, ERCP with sphincterotomy has achieved primacy in the management of bile duct stones. Sphincterotomy, mechanical lithotripsy, and stent placement are the fundamental techniques. If used appropriately, the biliary endoscopist may remove 80% to 90% of stones and may expect complications in fewer than 10% of cases.

Advanced endoscopic techniques for challenging bile duct stones

The management of difficult bile duct stones is a formidable challenge for the biliary endoscopist and has been the subject of extensive contemporary endoscopic research. Stone fragmentation may be accomplished by ESWL and intraductal methods of fragmentation, including electrohydraulic and laser lithotripsy. Intraductal treatment may be guided by fluoroscopy or choledochoscopy. Over the past decade, papillary balloon dilatation after endoscopic sphincterotomy has been introduced as a technique

Approach to bile duct stones in the patient with an intact gallbladder

The widespread introduction of ERCP and laparoscopic cholecystectomy has generated controversy regarding the best approach to patients with symptomatic bile duct stones and an intact gallbladder. Laparoscopic approaches to the bile duct are challenging and time consuming. Comparing the 2-stage approaches of ERCP along with laparoscopic cholecystectomy (Fig. 12) with laparoscopic cholecystectomy and laparoscopic common duct exploration (LCBDE) has been the subject of ongoing study and debate.

Summary

Bile duct stones are a source of significant morbidity, given their association with pancreatitis and cholangitis. Medical therapy for cholesterol and pigment bile duct stones aims to correct the biochemical aberrancies that lead to their formation. Hydrophilic bile salts and Rowachol decrease the biliary cholesterol supersaturation that underlies the formation of cholesterol stones. However, the modest efficacy of these agents relative to minimally invasive endoscopic and surgical

Acknowledgments

Special thanks are extended to Richard Molina, Kelvin Yeh, MD, and Arthur Yan, MD for assisting with figures.

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    Conflicts of interest: The author has nothing to disclose.

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