Choledocholithiasis is relatively common, seen in in 6-12% of patients who undergo cholecystectomy 2.
Stones within the bile duct are often asymptomatic and may be found incidentally, however, more frequently they lead to symptomatic presentation with:
Stones within the bile duct may form either in situ or pass from the gallbladder, and when recurrent tend to be pigment stones, and are thought to be associated with bacterial infection 1.
Although ultrasound is usually the first investigation for biliary disease, it has average sensitivity for the detection of biliary stones within the bile duct. Sensitivity has been variably reported between 13-55% 2, with newer studies having higher values due to improved equipment.
Ultrasound should be performed both longitudinally and transversely through the duct with particular attention paid to the very distal portion of the common bile duct as it passes through the pancreatic head (best assessed transversely).
- visualisation of stone(s)
- echogenic rounded focus
- size ranges between 2 to >20 mm
- shadowing may be more difficult to elicit than with gallstones within the gallbladder
- ~20% of common bile duct stones will not shadow
- twinkle artefact may be useful to detect occult stones
- dilated bile duct
- >6 mm + 1 mm per decade above 60 years of age
- >10 mm post-cholecystectomy
- dilated intrahepatic biliary tree
- gallstones should increase suspicion, especially if multiple and small
Recently endoscopic ultrasonography (EUS) has also been used with very high sensitivity and specificity.
Routine contrast-enhanced CT is moderately sensitive to choledocholithiasis with a sensitivity of 65-88% 3, but requires attention to a number of potentially subtle findings. These include:
- central rounded density: stone
- surrounding lower attenuating bile or mucosa
- rim sign: stone is outlined by thin shell of density
- crescent sign: bile eccentrically outlines luminal stone, creating a low attenuation crescent
- calcification of the stone: unfortunately only 20% of stones are of high density
Setting window level to the mean of the bile duct and setting the window width to 150 HU has been reported to improve sensitivity.
Biliary dilatation should also be visible.
CT with prior administration of biliary excreted contrast agents is highly sensitive (88-96%) and specific (88-98%) 8 for choledocholithiasis. The difficulty is, however, two-fold:
- contrast agents have relatively high complication rates
- obstructive cholestasis diminishes excretion, and thus is only viable in patients with largely normal liver function tests
Magnetic resonance cholangiopancreatography (MRCP) has largely replaced ERCP as the gold standard for diagnosis of choledocholithiasis, able to achieve similar sensitivity (90-94%) and specificity (95-99%) 7,8 without ionising radiation, intravenous contrast, or the complication rate inherent in ERCP.
Filling defects are seen within the biliary tree on thin cross-sectional T2 weighted imaging. Care should be taken not to use thick slabs for the diagnosis as volume averaging may obscure smaller stones.
However, if the diagnosis has already been secured by ultrasound or CT, there is no additional value of MRCP, and the next step is therapeutic ERCP (see below).
Percutaneous or oral cholangiography
Both investigations are no longer used for routine diagnosis having been replaced by ultrasound, CT and MRCP.
Treatment and prognosis
Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy is the treatment of choice for choledocholithiasis, however, is associated with a complication rate of 5.8-24% (10 years follow-up) 1.
Complications of ERCP and sphincterotomy include:
There is usually little differential, and differential will depend on the modality. The most frequent entities to consider include:
- other filling defects
- air bubbles
- partial volume averaging of bowel gas
- vascular calcification
- surgical clips
- MRCP specific potential pitfalls 6
- susceptibility artefacts
- flow voids
- vascular impressions
- sphincteric contraction or pseudocalculus sign
- galllbladder wall abnormalities
- diffuse gallbladder wall thickening (differential)
- focal gallbladder wall thickening (differential)
- gallbladder polyps
- gallbladder malignancy
- porcelain gallbladder
- gallbladder inflammation
- other gallbladder abnormalities
- 1. Sugiyama M, Suzuki Y, Abe N et-al. Endoscopic retreatment of recurrent choledocholithiasis after sphincterotomy. Gut. 2004;53 (12): 1856-9. doi:10.1136/gut.2004.041020 - Free text at pubmed - Pubmed citation
- 2. Cronan JJ. US diagnosis of choledocholithiasis: a reappraisal. Radiology. 1986;161 (1): 133-4. Radiology (abstract) - Pubmed citation
- 3. Miller FH, Hwang CM, Gabriel H et-al. Contrast-enhanced helical CT of choledocholithiasis. AJR Am J Roentgenol. 2003;181 (1): 125-30. AJR Am J Roentgenol (full text) - Pubmed citation
- 4. Caoili EM, Paulson EK, Heyneman LE et-al. Helical CT cholangiography with three-dimensional volume rendering using an oral biliary contrast agent: feasibility of a novel technique. AJR Am J Roentgenol. 2000;174 (2): 487-92. AJR Am J Roentgenol (full text) - Pubmed citation
- 5. Adamek HE, Albert J, Weitz M et-al. A prospective evaluation of magnetic resonance cholangiopancreatography in patients with suspected bile duct obstruction. Gut. 1998;43 (5): 680-3. Gut (link) - Free text at pubmed - Pubmed citation
- 6. Lin E, Garg K, Escott E et-al. Practical differential diagnosis for CT and MRI. Thieme Medical Pub. (2008) ISBN:1588906558. Read it at Google Books - Find it at Amazon
- 7. Chen W, Mo JJ, Lin L, Li CQ, Zhang JF. Diagnostic value of magnetic resonance cholangiopancreatography in choledocholithiasis. World journal of gastroenterology. 21 (11): 3351-60. doi:10.3748/wjg.v21.i11.3351 - Pubmed
- 8. Michael Maher, Jr., Adrian K. Dixon. Grainger & Allison's Diagnostic Radiology: Abdominal Imaging. ISBN: 9780702069383