Bile duct stone disease: symptoms and treatment of choledocholithiasis

Bile duct stone disease, medically known as choledocholithiasis, occurs when a gallstone or gallstones become lodged in any duct of the biliary system. The affected ducts are the common bile duct (choledochus), cystic duct and common hepatic (liver) ducts. When a stone is inside the gallbladder rather than a duct, the condition is called cholelithiasis in medical terminology.

The main function of the gallbladder, a small organ beneath the liver, is to store bile to help digestion. Gallstones developing in the gallbladder or its duct can have different chemical structures. There are 8 described types of gallstones, the most common being cholesterol stonesas a type.

Approximately 25 million people in America (around %10-15) are known to develop gallstones at some point in their lives.

Gallstones can range from microscopic size to the size of a walnut. Some people have one or two stones in the gallbladder, while others may have dozens. However, %80 develop silently without causing any symptoms. They are discovered incidentally through abdominal ultrasound and other radiological examinations.

Risk factors

• Being female and having high estrogen levels
• Pregnancy
• Receiving hormone treatment and using birth control pills
• Being over 40 years old
• Obesity
• Having metabolic syndrome, diabetes or high insulin resistance
• Eating a high-calorie diet with processed foods and little fiber 
• Rapid weight loss 
• A previous history of gallbladder or bile duct stone disease (it may recur, and sometimes gallstones continue to appear for another 3 years even after the gallbladder is removed)
• Having an infection of the biliary system is among the risks increasing gallstones.

Symptoms of bile duct stones

Pain is the most important symptom and may occur particularly after meals. Increasing pain in the upper right abdomen typically appears beneath the breastbone and may even spread to the shoulder.

Other symptoms include nausea and vomiting, fever, chills, yellowing of the skin and whites of the eyes, dark (tea-colored) urine and pale stools.

Gallstones and blocked ducts have important complications and can sometimes even be fatal. Because of complications such as inflammation and damage to the gallbladder and liver, gallstone pancreatitis (inflammation of the pancreas), and bacterial infection spreading into the blood, patients with bile duct stones are advised to remain under medical supervision and receive the necessary treatment. Stones inside the gallbladder generally cause no signs or symptoms.

How are bile duct stones diagnosed?

After assessment, doctors may use ultrasound, computed tomography (BT), magnetic resonance (MR) and endoscopic retrograde cholangiopancreatography (ERCP) as radiological examinations for diagnosis.

Blood tests assessing liver and gallbladder function may include bilirubin (total and direct), alkaline phosphatase, AST, ALT and GGT.

How is choledocholithiasis treated?

Small gallbladder stones, one or two in number and usually discovered incidentally, can sometimes be monitored for years without surgery. However, interventional procedures or surgery may be recommended for stones that move from the gallbladder into the duct and cause symptoms and potentially serious complaints, or that may be dangerous because of their location.

The most commonly used procedure is sphincterotomy (widening the duct opening) with ERCP. During ERCP, the liver and pancreatic ducts are viewed endoscopically using a tube with a light at its tip. A small incision called sphincterotomy is then made with the endoscopic device to remove the stone, and this duct empties into the small intestine. Other surgical methods involve removing the gallbladder and stone(s) in the duct through laparoscopic or open surgery.

The most effective treatment for active gallbladder disease is removal of the gallbladder. However, if there is inflammation or infection in the gallbladder or bile ducts, this should be treated first, followed by the interventions.