This document discusses the management of common bile duct (CBD) stones. It begins by describing the causes, symptoms, signs, and diagnosis of CBD stones. CBD stones can be primary (formed in the duct) or secondary (passed from the gallbladder). Diagnosis involves blood tests, ultrasound, MRCP, and ERCP. Treatment depends on whether stones are detected before, during, or after cholecystectomy. Options include ERCP sphincterotomy and stone extraction, laparoscopic CBD exploration, open CBD exploration, and surgery like choledochoduodenostomy. For retained stones, additional options are extracting through a T-tube or dissolving chemically. The goal is to remove stones using the least

1. Management of Common bile
duct stones
Dr. Arkaprovo Roy
Associate Professor,
Dept. of Surgery,
Medical College and Hospital
Kolkata

2. Causes of obstructive jaundice:
Benign Malignant
 Biliary atresia.  Carcinoma of head and periampullary region of the
pancreas.
 Choledochal cyst.  Cholangio carcinoma.
 CBD stones.  Klatskin tumour (Carcinoma at the confluence of
hepatic ducts above the level of the cystic duct and so
will cause hydro hepatosis without GB enlargement ).
 Chronic pancreatitis
 Ascending cholangitis.  Extrinsic compression of CBD by lymph nodes or
tumours.
 Biliary strictures  Carcinoma gall bladder
 Parasitic infestations

3. Common bile duct stones
Key facts:
• Common bile duct (CBD) stones present in
10% of patients with gallstones.
• Most pass from the gall bladder into the CBD
(secondary duct stones).
• Rarely form within the CBD (primary duct
stones); almost always associated with
partial duct obstruction.

4. CBD Stones
Secondary stones
• Formed within the gall
bladder and migrate down
the cystic duct to CBD
• More common type
• Usually are cholesterol
stones
Primary stones
• Formed per primam in the CBD
• Usually of the brown pigment type
• More common in Asian population
• The surgical significance of primary
CBD stone is that they are the
product of two conditions that must
be corrected in treating these stones
 Bile duct stasis and
 Infection

5. Symptoms:
• Choledocholithiasis may be asymptomatic
• May produce sudden toxic cholangitis
• Biliary colic, jaundice, or pancreatitis may be
isolated findings or
• May occur in any combination along with
signs of infection (cholangitis)

6. • Biliary colic from common duct obstruction
cannot be distinguished from that caused by
stones in the gallbladder.
• The pain is felt in the right subcostal region,
epigastrium, or even the substernal area.
• Referred pain to the region of the right
scapula is common.

7. • Choledocholithiasis should be strongly
suspected if intermittent chills, fever, or
jaundice accompanies biliary colic.
• Some patients notice transient darkening of
their urine during an attack even though
jaundice is not evident.

8. • Pruritus is usually the result of persistent,
long standing obstruction.
• The itching is more intense in warm weather
and is usually worse on the extremities than
on the trunk.
• It is much more common with neoplastic
obstruction than with stone obstruction.

9. Signs
• The patient may be icteric and toxic, with
high fever and chills
• May appear to be perfectly healthy
• Tenderness may be present in the right upper
quadrant
• Tender hepatic enlargement may occur.

10. Complications:
• Longstanding ductal infection can produce
intrahepatic abscesses.
• Hepatic failure or secondary biliary cirrhosis may
develop in unrelieved obstruction of long
duration.
• Cirrhosis - only after several years in untreated
disease.

11. • Acute pancreatitis.
• Rarely, a stone in the common duct may
erode through the ampulla, resulting in
gallstone ileus.
• Hemobilia (rare)

12. Diagnosis
• Laboratory investigations:
• In cholangitis, leukocytosis of 15,000/ L is usual,
and values above 20,000/ L are common.
• A rise in serum bilirubin often appears within
24 hours after the onset of symptoms.
• The absolute level usually remains under 10
mg/dL, and most are in the range of 2–4 mg/dL.

13. • The serum alkaline phosphatase level usually
rises and may be the only chemical abnormality
in patients without jaundice
• When the obstruction is relieved, the alkaline
phosphatase and bilirubin levels should return
to normal within 1–2 weeks
• Mild increases in AST and ALT are often seen
• Amylase and lipase: to document pancreatitis
• P-time / INR: usually less than 1.5
• GGT may be raised

14. Imaging:
USG:
• Ultrasonography can document stones in the
gallbladder and estimate the diameter of the
common bile duct.
• A dilated bile duct (>8 mm in diameter) on
ultrasonography in a patient with gallstones,
jaundice and biliary pain is highly suggestive of
choledocholithiasis.

15. MRCP
• MRCP provides excellent anatomic detail,
with sensitivity and specificity of 95% and
98%, respectively, for common bile duct
stones.
• It avoids the need for invasive ERCP in more
than 50% of patients.
• It can be used as a screening test for patients
at low or moderate risk for having common
duct stones before ERCP.

16. ERCP
• It is the diagnostic and potentially
therapeutic test of choice
• Cannulation of the ampulla of Vater and
diagnostic cholangiography are achieved in
more than 90% of cases

17. EUS:
• Endoscopic ultrasound (EUS) can also be
used to identify bile duct stones without
cannulation of the ampulla and its associated
risks, but it is less sensitive than ERCP.

18. • Magnetic resonance cholangiopancreatography(MRCP)
and endoscopic ultrasound (EUS) are both
recommended as highly accurate tests for identifying
CBD stones among patients with an intermediate
probability of disease.

19. Management
General measures:
• Maintain hydration and nutrition.
• Antibiotics: 3rd generation cephalosporine /
ciprofloxacin
• Injection Vitamin K – 10 mg IM once daily for
3 consecutive days.
• If INR is deranged: FFP

21. Definitive treatment
A. Before cholecystectomy-
Miminally invasive procedures:
Endoscopic Cholangiography
• The use of endoscopic cholangiography in
patients with suspected common bile duct
stones not only confirms the diagnosis but
also provides ductal clearance of the stones
and sphincterotomy before subsequent
laparoscopic cholecystectomy.

22. Good candidates for endoscopic therapy are:
• Patients with worsening cholangitis
• Ampullary stone impaction,
• Biliary pancreatitis,
• Multiple comorbidities, and
• Cirrhosis

23. • After endoscopic sphincterotomy and stone
extraction, patients with gallstones still
remain at high risk for developing future
biliary complications.
• Therefore, prompt cholecystectomy after
endoscopic clearance of the common bile
duct should be performed during the hospital
admission if the patient is fit for surgery.

24. • Endoscopic sphincterotomy is unlikely to be
successful in patients with large stones (eg, > 2
cm)
It is contraindicated in the presence of stenosis
of the bile duct proximal to the sphincter.
Stone location proximal to a stricture
Multiple impacted stones
For elderly (more than 70 years), poor risk patients
with both gall stones and CBD stones, ERCP can be
the sole treatment with no need for treatment of
asymptomatic gall stones.

25. • Patients with pancreatitis of suspected or proven
biliary origin who have associated cholangitis or
persistent biliary obstruction are recommended to
undergo biliary sphincterotomy and endoscopic
stone extraction within 72 hours of presentation.
• ERCP with stone extraction is the management of
choice for CBD stones.
• In spincterotomy sphincter is incised at 11o’clock
position to avoid injury to pancreatic duct

26. • The use of a biliary stent as sole treatment for CBD
stone should be restricted to a selected group of
patients with limited life expectancy and/or
prohibitive surgical risk.

27. B. With cholecystectomy
Laparoscopic Common Bile Duct Exploration
• An intraoperative cholangiogram at the time
of cholecystectomy will also document the
presence of common bile duct stones.
• Laparoscopic common bile duct exploration
through the cystic duct or with formal
choledochotomy allows the stones to be
retrieved during the same procedure.

28. • It is recommended that, in patients undergoing
laparoscopic cholecystectomy, transcystic or
transductal laparoscopic bile duct exploration
(LBDE) is an appropriate technique for CBD
stone removal.

29. Open surgery:
• Open Common Bile Duct Exploration
• With the increased use of endoscopic,
percutaneous, and laparoscopic techniques,
open common bile duct exploration is rarely
performed today.
• It should be performed when a concomitant
biliary drainage procedure is indicated.
• Open common bile duct exploration is
associated with low operative mortality and
morbidity.

30. • The rate of retained common bile stones
using intraoperative choledochoscopy is less
than 5%.
• If the CBD is not dilated T-tube drainage of
common bile duct is done.

31. • Stones impacted in the ampulla may be difficult
for both endoscopic ductal clearance and common
bile duct exploration.
• In these cases, transduodenal sphincteroplasty and
stone extraction should be performed.
• If this is not successful - choledochoduodenostomy
or a Roux-en-Y choledochojejunostomy should be
performed.

32. • Transduodenal sphincterotomy (TDS) is
useful when there is stone impaction in the
ampulla of Vater, papillary stenosis, and
multiple stones, particularly in the presence
of a nondilated bile duct.

33. • Choledochoduodenostomy is indicated in
patients with recurrent stones requiring
repeated interventions, impacted or giant
stones, biliary sludge, and ampullary stenosis.
• A common bile duct diameter of at least 1.2 cm
is important in assessing the feasibility of CDD
because this allows a wide enough stoma to
ensure good biliary drainage and avert stenosis.

34. Rendezvous technique
• It is a combined surgical, either laparoscopic or
open, endoscopic approach to common bile duct
stone treatment.
• The term Rendezvous (a French word meaning
appointment) was adopted when the surgeon and
the endoscopist met one other at the level of the
duodenum, the former by the way of a trans-cystic
guidewire and the latter with his lateral view
endoscope for biliary procedures, as originally
ideated by radiologists through percutaneous trans-
hepatic access.

35. • Recurrent CBD stone: if stone is found after 2
years of intervention.
• Retained CBD stone: if stone is found within 2
years of intervention.

36. Management of retained CBD stone:
C. After cholecystectomy
Preoperative diagnosis:
• Blood tests (elevated LFT’s)
• Abdominal U/S -15-30% sensitivity, If CBD
>10mm90%
• EUS - Sensitivity and specificity 92-100%
• MRCP - 90% sensitive, 100% specificity

37. ERCP:
• Diagnostic and therapeutic. Endoscope into
2nd portion of duodenum Papilla visualized &
cannulated – Radioopaque dye injected
under fluroscopy – Stones appear as filling
defects Performed in conjunction with
sphincterotomy and stone extraction.

38. • Various options are available to treat patients with
retained common bile duct stones.
• Management of an individual patient depends upon
the expertise and facilities available, the age and
general health of the patient, size of retained stones
and whether a T-tube is in place.
• They are:
• a) Mechanical nonoperative extraction
• b) Chemical dissolution
• c) Endoscopic sphincterotomy
• d) Surgical reoperation

39. • Retained stones in the common bile duct can
be removed if the T- tube is insitu, by saline
or heparinized saline flushed down the T-
tube.
• This method is indicated if the stones are
small and distal to the T-tube and the
sphincter of Oddi is relaxed with glycerol
trinitrate or glucagon.

40. • Extraction of stones via the T-tube tract using
steerable catheters is claimed to be the
procedure of choice in a selected group of
patients who have a T-tube.
• This procedure is done as a day case in the
radiology department after the T- tube has
been in place for 4 weeks or more and the
tract has ‘matured’. No fasting or
premedication are necessary.

41. • ERCP/sphincterotomy is also a valuable
method of treatment, however, it should be
avoided in patients who have had recent
surgery and aT-tube is in situ.

42. • Surgical re-exploration should be avoided if
these non-operative modalities are available
as it has a higher morbidity and mortality,
however, if the stones are large or when
complications arise as a result of
ERCP/sphincterotomy, it may become
necessary.

43. CBD stone
Detected or suspected prior to cholecystectomy:
• Do ERCP-
If negative – lap cholecystectomy
If positive – do ERCP Sphincterotomy and stone
extraction, followed by laparoscopic
cholecystectomy

44. CBD Stone
Detected or suspected at the time of
choklecystectomy:
• If expertise and instrumentation for
laparoscopic exploration is available – do
laparoscopic stone retrieval through the
cystic duct or choledochotomy
• If not available – complete cholecystectomy
and post the patient for ERCP/ open CBD
exploration

45. CBD Stone
Detected after cholecystectomy
Retained
• ERCP sphincterotomy and
stone extraction – if fails
and T – tube has been left
in place- stone removed
through T-tube tract
Recurrent
• ERCP sphincterotomy and
stone extraction
If above options fail – go for choledochojejunostomy

46. Thank you