Common bile duct stones

Abstract

Common bile duct stones (CBDS) are the most frequentcause of benign biliary obstruction requiring endoscopic treatment. Most CBDS are white to yellowish cholesterol stones or black pigment stones. They may appear as single or multiple calculi causing varying degrees of cholestasis or even biliary pancreatitis. The size ranges from small microconcrements to large stones in the order of several centimeters. CBDS smaller than the diameter of the bile duct migrate in the bile duct, and if they do not cause biliary obstruction, they may be asymptomatic and difficult to detect. Clinically relevant problems usually occur when stones get stuck and cholestasis develops. Stone extraction is required in patients with symptomatic CBDS and especially in those patients with biliary obstruction and with complications. Several methods for stone extraction exist including endoscopic, radiologic, and surgical approaches. Endoscopic retrograde cholangiopancreatography (ERCP) is less invasive than radiologic or surgical methods and therefore usually chosen as first-line treatment for stone extraction; however, ERCP bears the risk for severe procedure-associated complications such as pancreatitis, bleeding, cholangitis, and perforation. To reduce complications, unnecessary ERCPs should be avoided, and ERCP should only be performed for therapeutic stone extraction. This chapter describes diagnostic approaches and risk-based management options for CBDS.