Choledocholithiasis and cholangitis: Clinical sciences

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Introduction0:00–0:36

Choledocholithiasis occurs when one or more stones are present in the common bile duct. Stones are usually formed in the gallbladder, then pass through the cystic duct, get lodged in the common bile duct, and obstruct the bile outflow.
Occasionally, stones can even form in the common bile duct, called de novo choledocholithiasis. Because of the obstructed bile outflow, bacteria from the small intestine can colonize the common bile duct, leading to infection and inflammation, which is known as acute or ascending cholangitis.

Unstable branch0:36–1:04

When assessing a patient with suspected choledocholithiasis or cholangitis, you should first determine if your patient is stable or unstable by doing an ABCDE assessment.
If the patient is unstable, stabilize the airway, breathing, and circulation first. This means that you might need to intubate the patient, obtain IV access, or administer fluids before continuing with your assessment.

Stable branch1:04–3:22

Alright, so let’s see what’s next once the patient has been stabilized. Now, when it comes to stable patients, you have a bit more time to obtain the history and physical examination, as well as to draw labs, which can include CBC, CMP, amylase or lipase, lactate, and blood cultures.
Now, history usually reveals symptoms suggestive of cholangitis, like itchy skin from jaundice, as well as abdominal pain in the right upper quadrant, nausea, vomiting, and possible altered mental status.
Additionally, the history might also reveal some important risk factors for choledocholithiasis and cholangitis like biologically female sex, obesity, age over 40, or prior gallstones.
When it comes to the physical exam, it might reveal jaundice, and elevated temperature, as well as signs of biliary inflammation like tenderness to palpation in the right upper quadrant, possible guarding or rebound pain, and signs of hemodynamic instability, like tachycardia and hypotension.
Here’s a high-yield fact to keep in mind! The most important signs and symptoms of severe cholangitis can be summed up as Charcot triad, which includes right upper quadrant abdominal pain, jaundice, and fever; while patients who progress to sepsis may present with Reynolds pentad, which includes Charcot triad plus altered mental status and hypotension.
Keep in mind that these combinations won’t detect all the cases!Finally, labs might reveal leukocytosis, which is a sign of inflammation; as well as elevated alkaline phosphatase or ALP, GGT, LFTs including fractionated bilirubin showing elevated direct bilirubin, which are associated with liver and bile duct obstruction; and elevated lactate, which points to severe disease progressing to sepsis.
Although blood cultures are usually drawn in these patients, it may take days to get the results, so they are used later to help with the direction of antibiotic therapy.
Now, if signs and symptoms point to cholangitis, you should start supportive care immediately. This includes IV fluids, broad-spectrum antibiotics, pain management, and bowel rest.

Acute/ascending cholangitis3:22–5:26

Alright, once supportive care is started, you can move on to imaging, which usually means a bedside ultrasound. On ultrasound, patients with cholangitis have signs of bile duct dilation, meaning a common bile duct diameter greater than 7 mm; often with gallstones visible in the common bile duct; thickening of the bile duct walls; and sometimes even debris or pus visible in the gallbladder, which indicates biliary sludge.
However, if there are no signs of biliary tree etiology, consider alternative diagnoses.Okay, if imaging showed signs of cholangitis, you should continue the supportive care and monitor them carefully for complications.
The next step is emergent biliary drainage to relieve the pressure inside the biliary system, usually with endoscopic retrograde cholangiopancreatography, or ERCP for short.
Sometimes you won’t be able to perform ERCP. For example, if there is a gastric obstruction or surgically altered gastrointestinal anatomy like with gastric bypass, ERCP is not an option.
In this case, you can call the interventional radiologist for emergent percutaneous drainage. Lastly, if this fails, call the surgical team for emergent open drainage.
Now, if cholangitis was caused by a stone, you should recommend cholecystectomy after the patient has recovered from the acute phase, to prevent it from happening again.Now that we’re done with cholangitis, let’s go all the way back to the ABCDE assessment and talk about choledocholithiasis.

Choledocholithiasis5:26–7:43

You should obtain a history and physical exam, as well as labs. A patient with choledocholithiasis might report itchy skin from jaundice, right upper quadrant abdominal pain that radiates to the shoulder or scapula, nausea or vomiting, as well as changes in urine and stool color, like dark urine and pale stools.
As before, you might find some risk factors for choledocholithiasis or cholangitis in history, such as biologically female sex, obesity, age over 40, or history of prior gallstones.
On the other hand, a physical exam usually reveals mild tenderness to palpation in the right upper quadrant and jaundice.
Labs might reveal elevated alkaline phosphatase or ALP, GGT, and LFTs showing elevated direct bilirubin. Sometimes these patients can develop pancreatitis, so amylase and lipase might also be elevated.
Alright, if based on history and physical exam, you suspect choledocholithiasis, start supportive care. As before, this involves administering IV fluids, broad-spectrum antibiotics, pain medications if needed, and putting the patient on bowel rest.
Your next step is to order an ultrasound, which will help you diagnose the condition. So, if you see gallstones and possibly bile duct dilation on ultrasound, that’s choledocholithiasis.
However, if there are no signs of biliary tree etiology, consider alternative diagnoses. When it comes to treatment, you should first continue supportive care.
After that, order an ERCP to remove the stone and relieve the pressure in the biliary system. Then, call the surgical team for consultation and cholecystectomy to prevent another attack.
Finally, don’t forget to address any complications of choledocholithiasis such as pancreatitis. Alright, as a quick recap… Choledocholithiasis occurs when one or more stones obstruct bile outflow in the common bile duct.

Review7:43–8:54

This can allow bacteria from the small intestine to colonize the common bile duct, leading to infection and inflammation, which is known as acute or ascending cholangitis.
If you suspect choledocholithiasis or cholangitis, start supportive care. Next, an ultrasound is used to evaluate them, and confirm the diagnosis.
Patients with choledocholithiasis should be treated with supportive care and an ERCP to remove the stone. The final step is cholecystectomy, which will prevent any future attacks.
On the other hand, if the patient has acute cholangitis, start supportive care, and order an ERCP. If ERCP is not possible, interventional radiologists should be called for possible percutaneous drainage.
If this fails, call the surgical team for emergent surgical drainage. Finally, after the patient has recovered from the acute phase, cholecystectomy is recommended to prevent it from happening again.