Management of Common Bile Duct Stones

Primary Management Approach

Patients with confirmed common bile duct stones (CBDS) should be offered stone extraction through endoscopic, surgical, or radiological methods, as recommended by the British Society of Gastroenterology, rather than medical dissolution therapy 1, 2, 3, 4
The British Society of Gastroenterology strongly recommends active stone removal over conservative management for symptomatic patients, which directly addresses morbidity from pain, jaundice, infection, and acute pancreatitis 1, 2

Endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction is the primary therapeutic approach, requiring propofol sedation or general anesthesia for optimal success rates, and rectal NSAIDs (100 mg indomethacin or diclofenac) should be administered at the time of ERCP to reduce post-ERCP pancreatitis risk 1, 2, 5, 6, 7
Laparoscopic bile duct exploration (LBDE) during cholecystectomy is equally valid, with no difference in efficacy, mortality, or morbidity compared to ERCP, and is associated with shorter hospital stay 1, 2
Check FBC and INR/PT before biliary sphincterotomy 1, 2, 7

Ursodiol is contraindicated in patients with acute cholestasis, common bile duct obstruction, or non-functioning gallbladder, which are common features of CBDS 2, 5
Delaying definitive stone extraction in CBDS patients by attempting medical dissolution therapy increases the risk of complications, including cholangitis, pancreatitis, and hepatic dysfunction 1, 2