Gallstones, Choledocholithiasis and Cholangitis

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GI NOTES

Gallstones, Choledocholithiasis and Cholangitis

Key points

Asymptomatic gallstones usually need no treatment; symptomatic stones are treated with cholecystectomy.
Right upper quadrant ultrasound is the first test for biliary pain, cholecystitis and duct dilation.
Risk-stratify suspected bile duct stones: high risk goes straight to ERCP; intermediate risk gets MRCP or endoscopic ultrasound first.
Cholangitis is an emergency: fluids, blood cultures and antibiotics now, then biliary drainage, urgently if severe.
After a duct stone is cleared, remove the gallbladder to prevent recurrence.

1. The spectrum of gallstone disease

Condition	Typical picture	Management
Biliary colic	Steady RUQ or epigastric pain after meals, lasting 30 minutes to a few hours; normal labs	Elective laparoscopic cholecystectomy
Acute cholecystitis	Pain over 6 hours, fever, Murphy sign, raised WBC; thick wall and fluid on ultrasound	Antibiotics and early cholecystectomy (within 72 hours); percutaneous or EUS drainage if too unwell for surgery
Choledocholithiasis	Pain with raised bilirubin and alkaline phosphatase, dilated duct	Stone removal by ERCP (or surgical duct exploration), then cholecystectomy
Acute cholangitis	Fever, jaundice, RUQ pain (Charcot triad); may add confusion and shock	Antibiotics and biliary drainage
Gallstone pancreatitis	Pancreatic pain and lipase rise	See the Acute Pancreatitis note

2. Suspected bile duct stones (ASGE 2019)

FIGURE: RISK OF A COMMON BILE DUCT STONE

Symptomatic gallstones: check liver tests and ultrasound

High risk
Stone seen on imaging, or cholangitis, or bilirubin above 4 mg/dL with a dilated duct
→ ERCP

Intermediate risk
Abnormal liver tests, age over 55, or dilated duct alone
→ EUS, MRCP or intraoperative cholangiogram

Low risk
None of the above
→ Cholecystectomy without duct imaging

Original diagram based on the ASGE 2019 choledocholithiasis guideline.

ERCP is therapeutic, but carries a risk of pancreatitis (about 3 to 10%), bleeding and perforation, so avoid it for diagnosis alone.
Large or difficult stones: mechanical lithotripsy, large-balloon dilation, or cholangioscopy-guided lithotripsy.
If stones cannot be cleared, place a plastic stent to keep bile flowing and plan a second procedure.

3. Acute cholangitis

Diagnosis (Tokyo Guidelines 2018)

A. Systemic inflammation: fever or chills, or lab evidence (abnormal WBC, raised CRP).
B. Cholestasis: jaundice (bilirubin 2 mg/dL or more) or abnormal liver tests.
C. Imaging: biliary dilation, or evidence of the cause (stone, stricture, stent).
Suspected: A plus B or C. Definite: A, B and C.

Severity and drainage timing

Grade	Features	Drainage
Grade III (severe)	Organ dysfunction: shock needing pressors, confusion, respiratory failure, kidney injury, coagulopathy, low platelets	Urgent, once resuscitated, with organ support
Grade II (moderate)	Two or more of: WBC above 12 or below 4, fever 39 °C or higher, age 75 or older, bilirubin 5 mg/dL or higher, low albumin	Early (ASGE suggests within 48 hours)
Grade I (mild)	Neither of the above	If no response to antibiotics within 24 hours, or to treat the cause

Take blood cultures and start broad-spectrum antibiotics right away (for example piperacillin-tazobactam, or ceftriaxone plus metronidazole, guided by local resistance and prior instrumentation).
ERCP is the drainage method of choice; percutaneous or EUS-guided drainage if ERCP fails or anatomy is altered.
In unstable patients, a quick stent or nasobiliary drain without sphincterotomy is safer than full stone clearance.
Treat for about 4 to 7 days after the source is controlled.

4. Things to know

Risk factors for gallstones: female sex, pregnancy, obesity, rapid weight loss (including after bariatric surgery), cirrhosis, hemolysis, Crohn’s ileal disease, and some drugs (ceftriaxone, octreotide).
Ursodeoxycholic acid can prevent stones during rapid weight loss but rarely dissolves existing ones.
Acalculous cholecystitis occurs in critically ill patients; drainage by cholecystostomy is often needed.
Mirizzi syndrome: a stone in the gallbladder neck compresses the common hepatic duct.
Recurrent duct stones after cholecystectomy: consider primary duct stones, strictures or sphincter problems.

Self-check questions

A 60-year-old with biliary colic has raised alkaline phosphatase and a normal-caliber duct. What is the next step?
Fever, jaundice and hypotension needing norepinephrine. What grade, and when to drain?
Should incidental asymptomatic gallstones be removed?
After ERCP stone clearance, what comes next?

Answers: (1) Intermediate risk: EUS or MRCP (or intraoperative cholangiogram) before deciding on ERCP. (2) Grade III; urgent drainage once resuscitated. (3) Usually no. (4) Cholecystectomy, ideally during the same admission.

References

Buxbaum JL, Abbas Fehmi SM, Sultan S, et al. ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis. Gastrointest Endosc. 2019;89(6):1075-1105.
Buxbaum JL, Buitrago C, Lee A, et al. ASGE guideline on the management of cholangitis. Gastrointest Endosc. 2021;94(2):207-221.
Kiriyama S, Kozaka K, Takada T, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholangitis. J Hepatobiliary Pancreat Sci. 2018;25(1):17-30.
Yokoe M, Hata J, Takada T, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25(1):41-54.

For educational purposes only. This note does not replace clinical judgment or local protocols. Check doses against current labeling and institutional guidance.