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- Stones in common bile duct (CBD)
- Several types: cholesterol (majority), calcium bilirubinate or pigment, and mixed stones
- System(s) affected: gastrointestinal; hepatobiliary
- Synonym(s): CBD stones; CBD calculi
- Gallstone disease affects >20 million Americans.
- Choledocholithiasis noted in 7–12% of patients undergoing cholecystectomy for symptomatic gallstones
- Choledocholithiasis noted in 18–33% of patients with acute biliary pancreatitis
- Incidence increases with age (30–50% of patients >60 years with gallstones have concurrent CBD stones):
- Patients with choledocholithiasis are, on average, 10 years older than those with cholelithiasis.
- More common among patients >60 years
- Internationally, incidence is increased due to parasitic infections (e.g., Ascaris lumbricoides).
- Gallstone disease affects 10% of the U.S. population, at an annual cost of $6.2 billion.
- Twice as common among women
- Increased prevalence among Hispanics, Asians, Native Americans
Etiology and Pathophysiology
- CBD stones may be primary or secondary:
- Primary stones form within the biliary tract in conditions leading to bile stasis or chronic bactibilia.
- Secondary stones (more common) form within the gallbladder and migrate to the biliary tree.
- Stones may migrate to the duodenum or remain in the CBD (due to small diameter of Vater papilla). Not all CBD stones are symptomatic.
- Obstruction leads to jaundice. Bilostasis can trigger infection (e.g., ascending cholangitis).
- Dysfunction/obstruction of the CBD and/or main pancreatic duct can trigger acute pancreatitis.
- Chronic hemolytic states increase the risk for gallstone formation.
- Formation of de novo pigment stones can result from:
- Dilated, sclerosed, or strictured ducts (e.g., recurrent cholangitis)
- Hepatobiliary parasitism (A. lumbricoides or Clonorchis sinensis)
- MDR3 defects may predispose to biliary sludge, cholelithiasis, cholestasis of pregnancy, and subsequent choledocholithiasis.
- Variants of UGT1A1 responsible for bilirubin conjugation may increase cholesterol and pigment gallstone formation.
- Hepatobiliary cholesterol hemitransporter ABCG8 variant p.D19H doubles the odds of gallstone recurrence after cholecystectomy.
- Obesity; high caloric, low-fiber diet
- Chronic hemolysis
- Chronic estrogen exposure
- Rapid weight loss (>25% of original weight, especially after bariatric surgery) or prolonged fasting
- Prior cholecystectomy:
- <2 years prior: considered a “retained” stone
- >2 years prior: considered “recurrent” stone
- Maintain healthy weight and lifestyle. Avoid rapid weight loss.
- Consider UDCA therapy in LPAC syndrome.
Commonly Associated Conditions
- Cholelithiasis, cholecystitis, cholangitis
- Gallstone pancreatitis