Management of Choledocholithiasis

Initial Stabilization and Risk Assessment

Immediate biliary decompression is lifesaving in acute cholangitis and should be performed urgently (within 24 hours) in patients with severe sepsis or deteriorating despite antibiotics, as recommended by the American Gastroenterological Association 2, 1
For patients with suspected or proven biliary pancreatitis accompanied by cholangitis or persistent biliary obstruction, perform biliary sphincterotomy and stone extraction within 72 hours of presentation, according to the British Society of Gastroenterology 2
Initial medical management focuses on hemodynamic stabilization and treating local/systemic infections in acute biliary obstruction, as stated by the American College of Gastroenterology 1

Moderate-risk patients should undergo preoperative MRCP (93% sensitivity) or EUS (95% sensitivity) to confirm diagnosis before intervention, as recommended by the American College of Radiology 1
Alternatively, use intraoperative cholangiography or laparoscopic ultrasound with similar diagnostic accuracy, according to the Society of American Gastrointestinal and Endoscopic Surgeons 1

ERCP with sphincterotomy and stone extraction achieves 90% success in clearing the common bile duct, as stated by the American Society for Gastrointestinal Endoscopy 1, 2
For large stones (>10-15 mm), add mechanical lithotripsy or stone fragmentation techniques, which achieve 79% success rates, according to the European Society of Gastrointestinal Endoscopy 1
Consider endoscopic papillary balloon dilation combined with limited sphincterotomy for stones that cannot be safely extracted with sphincterotomy alone, as recommended by the American College of Gastroenterology 2

Percutaneous transhepatic approach achieves 95-100% success rates in experienced hands, according to the American College of Radiology 3, 1
Technique involves percutaneous access, balloon dilation of papilla of Vater, and pushing stones into duodenum with Fogarty balloon, as described by the Society of Interventional Radiology 3
For stones >15 mm, perform basket lithotripsy before balloon dilation, as recommended by the European Society of Gastrointestinal Endoscopy 3

Laparoscopic CBD exploration is now preferred over open surgery with 95% success rates and 5-18% complication rates, according to the Society of American Gastrointestinal and Endoscopic Surgeons 3, 1
Generally indicated when CBD is wide (>9 mm) to avoid subsequent stricture development, as stated by the American College of Surgeons 3

Do not delay biliary decompression beyond 24 hours in patients with severe sepsis or deteriorating cholangitis despite antibiotics, as warned by the American College of Gastroenterology 2, 1
Recognize that elderly patients have nearly double the complication rate (19% vs 6-10%) with endoscopic sphincterotomy, according to the American Geriatrics Society 1
Avoid first trimester ERCP in pregnant patients when possible due to poorer fetal outcomes, as recommended by the American College of Obstetricians and Gynecologists 1
Do not assume all stones can be extracted endoscopically—have backup plan for percutaneous or surgical approach, as stated by the American College of Radiology 3, 1