Common Bile Duct Stones (CBDS)
Discuss common bile duct stones?
The natural history of secondary CBDS (stones that slip from gallbladder in to CBD) is not well understood. What is clear is that when ductal stones do become symptomatic the
consequences are often serious and can include pain, partial or complete biliary obstruction, cholangitis, hepatic abscesses or pancreatitis. Chronic obstruction may also cause secondary biliary cirrhosis and portal hypertension. It is thus recommended that CBDS always need extraction. This applies even in cases where cirrhosis has developed, as reversal of hepatic fibrosis has been observed following relief of chronic biliary obstruction
Discuss the investigations for CBD stones?
- Transabdominal USS is not very sensitive
- EUS and MR are both highly effective for confirming the presence of CBDS. Prospective studies has failed to show a statistically significant difference in performance when the two modalities are compared, though for small CBD stones EUS may still be more sensitive. Choice of test therefore depends on local expertise.
- CT scan- recent studies suggest helical CT can diagnose CBDS with sensitivity and specificity that is comparable to MR cholangiography
Discuss the endoscopic treatment of CBDS?
ERCP can be used to provide definitive or temporary treatment of CBDS. ERCP is reserved for patients with confirmed or high suspicion of CBDS. ERCP should not be used as a diagnostic test.
Biliary sphincterotomy (BS) followed by stone extraction using a basket or balloon catheter represents standard endoscopic therapy for CBDS.
It is important that endoscopists ensure adequate biliary drainage is achieved in patients with CBDS that have not been extracted. Bacterial contamination of bile is common in
patients with CBDS and incomplete duct clearance may therefore place patients at risk of cholangitis. It is therefore important that a biliary stent be inserted where stones cannot be extracted. The short-term use of an endoscopic biliary stent followed by further ERCP or surgery has been shown to be a safe management option in this setting. In contrast the use of a biliary stent as sole treatment for CBDS should be restricted to a selected group of patients with limited life expectancy and/or prohibitive surgical risk.
BS can be safely performed on patients taking aspirin or non-steroidal anti-inflammatory drugs. Administration of low dose heparin should not be considered a contraindication to BS. Where possible, newer anti-platelet agents such as clopidogrel
should be stopped 7–10 days prior to BS.
PS- Patients with acute cholangitis who fail to respond to antibiotic therapy or who have signs of septic shock require urgent biliary decompression. Biliary sphincterotomy, supplemented by stenting or stone extraction, is therefore indicated.
Discuss the surgical treatment of CBDS?
Surgical treatment of CBDS occurs in the setting of concurrent laparoscopic cholecystectomy.
Patients with CBDS undergoing laparoscopic cholecystectomy may be managed by laparoscopic common bile duct exploration (LCBDE) at the time of surgery, or undergo
peri-operative ERCP. There is no evidence of a difference in efficacy, morbidity or mortality when these approaches are compared, though LCBDE is associated with a shorter hospital
stay. The two approaches are considered equally valid treatment options.
Discuss cholecystectomy for CBDS?
Cholecystectomy is recommended for all patients with CBDS and symptomatic gallbladder stones, unless there are specific reasons for considering surgery inappropriate
In patients with CBDS cholecystectomy may be performed routinely or reserved for those who develop recurrent biliary symptoms following ERCP. Randomised control studies comparing these two approaches suggest 15–37% of patients whose gallbladder is left in situ will develop symptoms that require cholecystectomy during a follow-up period ranging from an average of 17 months to over 5 years. Recurrent symptoms following ESE are most likely to be reported by younger, surgically fit patients with radiologically proven gallstones.
Deferred laparoscopic cholecystectomy in this group is associated with higher rates of conversion to open surgery and a greater risk of surgical complication.
Therefore in patients with CBDS and gallstones endoscopic stone extraction as sole
treatment should be avoided unless there are patient related factors that make cholecystectomy inappropriate.
Discuss the complications of ERCP?
Post-ERCP pancreatitis- 1.5%
Gastrointestinal haemorrhage- 0.9 (1.5% of BS patients)
Cholangitis- 1.1%
Duodenal perforation- 0.4%
Miscellaneous, including cardio respiratory- 1.4%
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