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Choledocholithiasis: Causes, Symptoms, Diagnosis, Treatment, and Prevention

Choledocholithiasis is a medical condition that occurs when one or more stones (also called gallstones) form in the common bile duct, which carries bile from the liver and gallbladder to the small intestine. The fluid bile helps the body digest fats and remove wastes.

Causes of Choledocholithiasis

Choledocholithiasis can be caused by several factors, such as :

• Cholesterol stones: These are the most common type of gallstones, and they form when there is too much cholesterol in the bile. They are usually yellow or green in color.

• Pigment stones: These are less common than cholesterol stones, and they form when there is too much bilirubin in the bile. Bilirubin is a pigment that results from the breakdown of red blood cells. They are usually black or brown in color.

• Biliary sludge: This is a mixture of bile, calcium, and cholesterol crystals that can accumulate in the gallbladder or the bile ducts. It can act as a precursor for stone formation or cause blockage by itself.

• Infection: Bacterial infection of the bile ducts can cause inflammation and scarring, which can lead to stone formation or obstruction.

• Anatomy: Some people have anatomical variations or abnormalities in the bile ducts, such as narrowing, diverticula, or cysts, which can increase the risk of choledocholithiasis.

Symptoms of Choledocholithiasis

Choledocholithiasis may not cause any symptoms if the stones are small and do not block the bile flow. However, if the stones are large or cause obstruction, they can cause the following symptoms :

• The most common symptom of choledocholithiasis is pain in the upper right abdomen, radiating to the back or right shoulder. The pain may be sudden, severe, intermittent, or dull, constant, and mild. The pain may be triggered by eating fatty or greasy foods, or may happen for no apparent reason at all.

• Symptoms of jaundice include yellowing of the skin and the whites of the eyes, which occurs when bile cannot flow into the intestine and accumulates in the blood.

• Choledocholithiasis can cause fever, chills, nausea, vomiting, and loss of appetite, which are symptoms of infection or inflammation of the bile ducts.

• It is the inflammation of the pancreas, a gland that produces digestive enzymes and hormones, that causes pancreatitis, a serious condition. Choledocholithiasis can lead to pancreatitis if stones block the pancreatic duct, which connects the pancreas to the common bile duct. Pancreatitis can cause severe abdominal pain, nausea, vomiting, and low blood pressure.

Diagnosis of Choledocholithiasis

Choledocholithiasis can be diagnosed by a combination of medical history, physical examination, blood tests, and imaging tests, such as :

• Using sound waves, ultrasound creates images of the internal organs in a non-invasive manner. The ultrasound can detect gallstones in the gallbladder and bile ducts, as well as their size and location. However, ultrasound may not be able to detect small stones or stones hidden in gas or bowel contents.

• A flexible tube with a light and camera (called an endoscope) is inserted through the mouth, esophagus, stomach, and duodenum (the first part of the small intestine) to reach the common bile duct during endoscopic retrograde cholangiopancreatography (ERCP). To visualize stones and blockages, endoscopes are used to inject dye into the bile ducts and pancreatic ducts and then take x-rays. ERCP can also be used to remove stones or place a stent (a small tube) to relieve obstructions.

• With magnetic resonance cholangiopancreatography (MRCP), images of the pancreatic duct and bile duct are created using radio waves and magnetic fields. It is possible to detect stones and blockages with MRCP without using dye or endoscopy. However, MRCP cannot be used to treat stones or obstructions.

• Other tests: These may include liver function tests, which measure the levels of enzymes and bilirubin in the blood, and blood cultures, which check for the presence of bacteria in the blood.

Treatment of Choledocholithiasis

The treatment of choledocholithiasis depends on the size, number, and location of the stones, the severity of the symptoms, and the presence of any complications. This treatment aims to remove the stones, relieve obstruction, and prevent infection and inflammation. Treatment options include:

• Small cholesterol stones can be dissolved over a period of months or years with some medications, such as ursodeoxycholic acid and chenodeoxycholic acid. These medications are not effective for pigment stones or large stones, and they can cause diarrhea, nausea, and abdominal pain. Moreover, they may recur after stopping use.

• An endoscopic sphincterotomy (ES) is typically performed in conjunction with ERCP, during which a small incision is made in the sphincter of Oddi, which controls the opening of the duodenum to the common bile duct. By creating a permanent opening in the sphincter, ES can also prevent recurrences of stones by allowing them to pass through the duct or be removed with a basket or balloon attached to the endoscope. ES, however, may result in complications such as bleeding, infection, perforation, or pancreatitis.

• Extracorporeal shock wave lithotripsy (ESWL): ESWL breaks up stones into smaller pieces by using sound waves, which are then passed through the duct or removed using ERCP. ESWL is generally reserved for patients who cannot undergo ERCP or ES, or who have stones that are too large or too hard to be removed using these procedures. ESWL is not effective for all types of stones, and it can cause pain, bruising, and infection as side effects.

• An incision is made in the abdomen in order to remove the stones from the bile ducts during this procedure. There are two types of surgery: open surgery, which involves making a large incision, and laparoscopic surgery, which involves making several small incisions and inserting a camera and instruments. A surgery may also involve removing the gallbladder, the source of most gallstones, in order to prevent choledocholithiasis from recurring. As a last resort, surgery may be recommended when other methods have failed or are not feasible, or there are serious complications such as gangrene, perforation, or abscess. Surgery may cause bleeding, infection, or damage to nearby organs.

Prevention of Choledocholithiasis

Choledocholithiasis can be prevented by reducing the risk factors that contribute to gallstone formation, such as :

• In order to prevent cholesterol stones, you should eat a balanced diet that is low in fat and cholesterol, high in fiber, fruits, and vegetables. Keeping your bile thin and flowing by avoiding rapid weight loss or fasting can also help you prevent cholesterol stones. Keeping the bile thin and flowing can help prevent both cholesterol stones and pigment stones if you drink enough water and fluids.

• In addition to maintaining a healthy weight, exercise can also lower cholesterol levels in the blood and bile, reducing the risk of cholesterol stones. As a result of exercise, the gallbladder and bile ducts can be more motile, preventing stagnation of bile and stones formation.

• It has been shown that certain medications, such as oral contraceptives, hormone replacement therapy, and cholesterol-lowering drugs, can increase cholesterol stone risk by altering the composition of bile. As a result, these medications need to be taken with caution and under doctor's supervision. Those with a family history of gallstones or who have had bariatric surgery may benefit from taking medications containing ursodeoxycholic acid, which dissolves or prevents cholesterol stones.

• Having regular check-ups and screening tests, such as ultrasounds or blood tests, can help detect gallstones or choledocholithiasis before they cause symptoms or complications. It is possible to reduce the need for invasive procedures and surgery by detecting and treating the condition early.