Choledocholithiasis

Learning Objectives:
Appropriate triage?
Indications for antibiotics in choledocholithiasis?
indications for cholecystecomy

High probability of choledocholithiasis has been defined as:
1. CBD stone on U/S or CT  or
2. At least 3 of the following: dilated CBD on US (>7 mm), fever, bilirubin >2 mg/dL, elevated alkaline phosphatase, or serum alanine aminotransferase (ALT) >twice normal.
See Harrison's Table 305-3 for a summary of diagnostic studies for CBD stones

Appropriate Triage:
Inpatient vs Outpatient? 2A, tele, ICU or IICU?
Diagnosis of choledocholithiasis should be followed by stone removal asap to prevent complication
This MAY require admission for expedited imaging, ERCP, cholecystectomy, etc
Indications for IICU triage are related to complicated choledocholithiasis.
The 2 most concerning complications are pancreatitis and cholangitis
In the absence of clinical infection, pancreatitis or SIRS physiology, these patients can be managed on the medicine ward while being evaluated

Antibiotics in Choledocholithiasis?
Our patient was started on ciprofloxacin as an outpatient after an ED visit with reported subjective fever; exam, however, was not consistent with cholangitis
Recall that cholangitis is one of the most dangerous complications of CBD stones
Acute cholangitis involves biliary pain, jaundice, and spiking fevers with chills (Charcot's triad). Leukocytosis and Bacteremia are frequently present
There is no need for empiric abx in patients with choledocholithiasis in the absence of cholangitis
Rather than antibiotics, the definitive treatment for uncomplicated choledocholithiasis is stone removal

Indications for Cholecystectomy?
Even those who have low probability for CBD stones should receive cholecystectomy if they have known cholelithiasis
IF CBD stones are suspected prior to laparoscopic cholecystectomy, preoperative ERCP with endoscopic papillotomy and stone extraction is recommended
Our patient had an ERCP within 48hrs and will have a lap cholecystecomy as an outpt for definitive therapy

Ref:
Canto, et al. Endoscopic ultrasonography versus cholangiography for the diagnosis of choledocholithiasis.Gastrointest Endosc. 1998;47(6):439-48.
ASGE Standards of Practice Committee. The role of endoscopy in the evaluation of suspected choledocholithiasis. Gastrointest Endosc 2010; 71:1
Harrison's Ch 305 Diseases of the Gallbladder and Bile Ducts
Current Med Diagnosis and Treatment: Liver, Gallbladder, and Pancreatic disorders

(Ellen Eaton MD, 1/28/11)