Choledocholithiasis - Causes, Symptoms, and Treatment

Introduction

The common bile duct is a part of the biliary system in the body. The common bile duct is formed where the ducts of the liver and gallbladder join. The gallbladder is a pear-shaped organ located in the upper right abdominal area below the liver. The common bile duct is a small duct that carries the fluid bile from the gallbladder and liver through the pancreas into the small intestine area. Bile is a fluid made and secreted by the liver that helps digestion. It contains bile salts, cholesterol, and bilirubin.

What Is Choledocholithiasis?

Choledocholithiasis is characterized by the formation of gallstones in the common bile duct. Choledcho is a Latin word for common bile duct, and lithiasis refers to stone. Gallstones are pebble-shaped small stones containing bile materials like cholesterol or bilirubin. These gallstones usually develop in areas where the bile flows.

What Causes Choledocholithiasis?

The liver is an endocrine organ in our body. The liver makes bile out of materials it filters from the blood. These materials include bile salts, cholesterol, lecithin, and bilirubin. Gallstones form when either one of these materials increase in the blood. This usually happens with cholesterol and sometimes with bilirubin. The excess materials turn into sediments. The sediments get collected at the bottom of the gallbladder or the common bile duct and harden to a stone. The stones slowly grow as the sediments continue to wash over them. It usually takes over many years. Most gallstones usually form in the gallbladder and travel with bile into the common bile duct.

What Are the Symptoms Seen in Choledocholithiasis?

Choledocholithiasis is usually asymptomatic until the gallstones cause a blockage. The symptoms usually start developing when the stone blocks the common bile duct. This blockage causes biliary colic. Biliary colic is a dull abdominal pain that occurs from the middle abdominal region up to the upper right region. Other symptoms include

• Abdominal pain usually starts after meals and can last from an hour to several hours. It grows in the first twenty minutes and gradually reduces after that. The pain is most felt in the upper right abdomen and can also radiate toward the right side of the shoulder blade region.

• Pain in the abdominal region is also accompanied by nausea and vomiting.

• A lack of appetite can be noted when the abdominal pain is not severe.

• Fever occurs when there is severe inflammation in the biliary system. When the bile duct gets blocked, bacteria accumulates in the region since it is not flushed out. This can cause an infection leading to fever.

• When bile leaks into the bloodstream, it shows up as a yellow tint in the skin or the white region of the eyes. It can also make the urine a darker color. Jaundice symptoms, like biliary colic, usually come and go until the blockage is cleared.

What Are the Complications Seen in Choledocholithiasis?

When the gallstone blocks the common bile duct, bile accumulates behind the blockage. This accumulation affects the bile duct and other organs connected to it, like the pancreas, gallbladder, and liver. In addition, it causes further inflammation, infection, and long-term damage to the tissues.

• Infections - With the blockage, bacteria accumulate in the region, causing an infection. Infections caused in the biliary systems are usually dangerous as they can spread to the liver and the bloodstream. An infection in the bloodstream is called septicemia, which can lead to life-threatening complications like sepsis.

• Cholangitis - It is an infection or inflammation of the common bile duct. An infection or inflammation in the common bile duct can spread into its branches, including the branches that run through the liver; this, in turn, causes liver swelling.

• Cholecystitis - It is an inflammation in the gallbladder. The bile which gets accumulates in the gall bladder causes swelling. Swellings can be painful and stop the gallbladder from functioning adequately, eventually damaging it.

• Gallstone Pancreatitis - The pancreas and bile ducts share the same exit channel to the intestines. When gallstones block the same common channel, it also blocks the pancreatic secretions. This pancreatic secretion contains potent enzymes that back up into the pancreas and causes inflammation called pancreatitis which further leads to organ damage.

What Are the Risk Factors Associated With Choledocholithiasis?

The chances of gallstones are mostly seen in people with high cholesterol levels and more in females than males due to female hormones.

• High Cholesterol Levels - Most gallstones are formed due to extra cholesterol in the blood. Bile ingredients like lecithin and bile salts usually emulsify cholesterol. But if an imbalance occurs between them, the emulsification doesn't happen, leading to an excess cholesterol level in the blood.

• Female Hormones - Hormones like estrogen and progesterone are higher during certain periods of a woman's reproductive life and during hormone replacement therapies. The estrogen hormone increases cholesterol levels, and progesterone slows down gallbladder contractions. This slowing down will increase the sedimentation rate leading to the formation of gallstones.

Gallstones in the common bile duct are common for people who have had gallstones before and also in conditions like chronic cholangitis.

• The Previous Occurrence of Gallstones - People who have had gallstones before are more likely to have them again. Even when the gall bladder is removed to treat gallstones, stones are likely to develop in the bile ducts.

• Chronic Cholangitis - Choledocholithiasis usually causes cholangitis, but in some cases, cholangitis can cause choledocholithiasis.

How Is Choledocholithiasis Diagnosed?

The healthcare provider will take a detailed history of symptoms and confirm the diagnosis with blood tests and imaging tests.

Blood Tests - Blood tests include complete blood count, bilirubin test, liver function test, and pancreas function tests. These tests are used to check infections and the proper functioning of the liver and pancreas.

Imaging Tests - Imaging tests include abdominal ultrasound, endoscopic ultrasound, MRCP, and ERCP.

• Abdominal Ultrasound - Ultrasound is a non-invasive test that can give early clues about the condition. An abdominal ultrasound checks for the presence of gallstones in the gallbladder region. Even though it cannot visualize the common bile duct, it shows whether the duct is dilated; dilation is a sign of a blockage.

• Endoscopic Ultrasound - It combines an ultrasound test with an upper endoscopy to get a clear picture of the bile ducts. In the endoscopy procedure, an endoscope (a tiny camera lighted on a tube ) is passed down to the throat into the gastrointestinal tract. The ultrasound probe at the end of the endoscope transmits sound waves that produce images of the biliary system.

• Magnetic Resonance Cholangiopancreatography (MRCP) - MRCP is a type of MRI (magnetic resonance imaging) that can specifically visualize the bile duct.

• Endoscopic Retrograde Cholangiopancreatography (ERCP) - An ERCP combines X-rays and endoscopy. This procedure is a little more invasive as it is used to find and remove gallstones.

How Is Choledocholithiasis Treated?

If an infection is present, antibiotics are given to treat the infection before the removal of gallstones.

In case of accumulated bile, and biliary drainage is done to remove them.

Gallstones in the bile duct are mainly treated by easing the blockage. Some treatments include

• Biliary Endoscopic Sphincterotomy (BES) - BES is the most common treatment option for treating gallstones; about 85 percent of the stones are removed with the biliary endoscopic sphincterotomy procedure. In this procedure, a balloon-like device is inserted into the bile duct, and the stones are extracted.

• Fragmenting the Stones (Lithotripsy) - The stones are fragmented to pass easily in this procedure.

• Sphincterotomy - In this procedure, a cut is made in the common bile duct to remove stones or to help them pass through the urine.

• Cholecystectomy - It is a surgical procedure done to remove stones and gallbladder.

How Can Choledocholithiasis Be Prevented?

If a bile duct stone occurs once, it can occur again. However, lifestyle modifications like including exercise in your daily routine and changing dietary habits by increasing fiber content and decreasing the intake of saturated fats can help reduce the chances of developing stones in the future.

Conclusion

Choledocholithiasis is a condition where gallstones are formed in the common bile duct region. These stones cause various symptoms, like abdominal pain, loss of appetite, fever, and jaundice. Choledocholithiasis treatment mainly involves the removal of these stones, thereby relieving the symptoms. This condition can be adequately prevented by making certain lifestyle modifications like changes in dietary habits and exercising regularly.