Choledocholithiasis and cholangitis: Clinical sciences

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.

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.

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. 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.