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Case 056: Common bile duct stones (choledocholithiasis).

Author: John Wong MBChB, FRCSEd

David C Chung MD, FRCPC
Affiliation: The Chinese University of Hong Kong

Mr. SF, a 50 year old lorry driver, presented to the local hospital complaining of
upper abdominal pain. He described the discomfort as a gnawing bloated feeling
centered around the epigastrium that came on in the middle of the night 2 days ago.
He noticed he had a fever the next morning and visited his family doctor who
prescribed an antibiotic together with dietary instructions for gastroenteritis. His fever
subsided the next day but he continued to experience anorexia, nausea, and malaise
and he noticed his urine was dark like strong tea. The color of his stool was, however,
brown and normal. He admitted to having had 2 similar but milder attacks in the last
6 months and recovery was spontaneous within several hours. Otherwise he has
been healthy in the past; was free of ischemic heart disease, hypertension, diabetes,
and allergies; and was not on any chronic medication. Functional enquiry was not
contributory.

Examination revealed a mildly obese middle age man who had yellow discoloration
of his sclera and skin. His vital signs were: oral temperature 37.4 oC, oxygen
saturation on room air 98%, BP 144/86 mmHg, pulse rate 92/min, respiratory rate
20/min. There was some tenderness but no guarding at the epigastrium and there
was no organomegaly. Examination of the cardiorespiratory systems yielded normal
findings.

Results of laboratory investigations were:

Complete Blood Count Reference range

Red cell count 4.51 1012/L 4.20 – 5.70
Hemoglobin 13.8 g/dL 13.2 – 16.7
HCT 0.402 L/L 0.39 – 0.50
MCV 89.1 fL 81.0 – 97.0
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MCH 30.5 pg 27.0 – 32 0

MCHC 34.3 g/dL 31.0 – 35.0
Platelet count 298 109/L 140 – 380
White cell count 4.9 109/L 4.0 – 10.8

Plasma Reference range

Sodium 136 mmol/L 134 – 145
Potassium 3.8 mmol/L 3.5 – 5.1
Urea 3.5 mmol/L 3.4 – 8.9
Creatinine 86 µmol/L 62 – 106
Total protein 78 g/L 66 – 81
Albumin 40 g/L 36 –48
Total bilirubin 194* µmol/L < 15
Total ALP 311* IU/L 35 – 100
ALT/GPT 322* IU/L < 58
Calcium 2.55 mmol/L 2.15 – 2.55
Phosphate 0.86 mmol/L 0.82 – 1.40
LDH 158 U/L 87 – 213
Amylase 37 U/L 28 – 100

Coagulation screen
PT 10.7 sec
INR 0.96 0.9 – 1.10
APTT 32.0 sec 24.2 – 37.0

Abdomen ultrasound report

ƒ Multiple gallstones noted in gallbladder which is not thickened or distended.
ƒ Intra-hepatic and common bile ducts (CBD) dilated but no ductal stones
seen.
ƒ Distal CBD and pancreas obscured by bowel gas.
ƒ Liver, kidneys, urinary bladder, and spleen normal.
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1. What are the differential diagnoses?

This patient’s clinical presentation and laboratory findings are suggestive of CBD
obstruction. Causes of CBD obstruction include CBD stones, cholangio-
carcinoma, carcinoma of the head of pancreas, and external compression by
lymph nodes at the porta region. In the context of this patient the most likely
cause of obstruction is stone in the CBD.

2. Where do CBD stones come from?

Stones lodged in the CBD can come from the gallbladder or arise de novo in a
tortuous duct due to stasis and infection. In oriental patients only, stones can
come from the intra-hepatic bile ducts as a result of recurrent pyogenic
cholangitis.

3. What are the clinical features of CBD obstruction?

Obstruction of the CBD can be chronic or acute and the clinical features can be
confused with those of acute cholecystitis (see “Case 3: Acute Cholecystitis” on
http://www.medicine-on-line.com). Helpful differentiating features include:

Clinical features Acute cholecystitis CBD obstruction

Dark color urine* Absent May be present
Clay color stool* Absent May be present
Jaundice Mild if present Severe
Murphy’s sign Present Absent
Liver enzymes Mildly increased if present Markedly increase,
especially ALP
* Dark color urine is due to increase in urobilinogen content and clay-color stool
from absence of bile).
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The most important diagnostic tool is ultrasonography of the biliary tree.

Technical difficulty can obscure the distal end of the CBD as in this patient, but
demonstration of a dilated proximal duct and intra-hepatic ducts is convincing
evidence of distal obstruction.

4. What should be the follow-up investigation and treatment for this

patient?

The patient should have an endoscopic retrograde cholangiopancreatography

(ERCP), which can help to confirm whether the obstruction is due to tumor or
stone. If obstruction from stone is confirm, a sphincterotomy together with basket
or balloon extraction of stone can be performed. Endoscopic removal of stone
should be followed by cholecystectomy, preferably by the laparoscopic route, so
as to remove any future source of stone.

It should be remembered that CBD obstruction by stone is a frequent cause of

acute bacterial cholangitis. Infective organisms are usually E. coli, Bacteroides,
Klebsiella, or Clostridium species. In preparation of patients for ERCP, they
should be given supportive treatment and their management plan should include:
o Keep patient nil by mouth and maintain hydration normal by the intravenous
route.
o Prescribe an opioid analgesic for pain relief.
o Treat suspected sepsis or start antibiotic prophylaxis with a third generation
cephalosporin together with metronidazole.
o Optimize patient’s condition if he has concurrent illnesses.

Progress of the Case—The patient had an ERCP which confirmed multiple stones in
the CBD. A sphincterotomy was performed in the same setting and the stones were
crushed with an electro-hydraulic lithotripter and then removed with basket and
balloon. He had an uneventful laparoscopic cholecystectomy 2 days later and was
discharged home the following day.
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Further reading

Ruiz O. Cholelithiasis and cholecystitis. In Rakel: Conn’s Current Therapy, 58th

edition. Saunders;2006.

Ahmed A et al. Management of gallstones and their complications. American Family

Physician 2000;61:1673-80.