Choledocholithiasis: A Contemporary Review of Its Clinical Impact And Management Strategies
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Abstract
Introduction: Choledocholithiasis, defined as the presence of stones in the common bile duct, represents a frequent cause of biliary obstruction and complications such as cholangitis and acute pancreatitis. Its prevalence is estimated at 10–20% in patients with cholelithiasis, increasing in older adults and in the presence of metabolic or anatomical predisposing factors.
Clinical presentation: Manifestations range from asymptomatic forms to severe clinical scenarios. Right upper quadrant pain, jaundice, choluria, and acholia are the predominant symptoms and may be accompanied by fever or sepsis in cases of cholangitis. Elevations in transaminases, even when marked, do not exclude the diagnosis.
Diagnosis: Evaluation is based on the combination of clinical, biochemical, and imaging criteria, with risk stratification according to ASGE and WSES guidelines. Endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP) are the most accurate methods for confirming the diagnosis in patients at intermediate risk, whereas endoscopic retrograde cholangiopancreatography (ERCP) is reserved for therapeutic purposes.
Treatment and prognosis: ERCP with stone extraction and sphincterotomy is the treatment of choice, followed by early cholecystectomy, ideally during the same hospital admission, which reduces recurrence and complications. In refractory cases, advanced endoscopic, percutaneous, or surgical approaches may be considered. Prognosis depends on timely biliary drainage and control of sepsis, with recurrence rates reaching up to 30% depending on anatomical and technical factors.
Conclusion: Choledocholithiasis requires a stratified diagnostic approach and comprehensive evidence-based management, in which early intervention and recurrence prevention are key to optimizing clinical outcomes. Furthermore, in secondary and tertiary care hospitals, the standardization of diagnostic-therapeutic pathways (risk stratification, rational selection of EUS/MRCP, and ERCP–cholecystectomy coordination during the same admission) represents a high-impact intervention to reduce unnecessary procedures, readmissions due to recurrent biliary events, and complications associated with delayed biliary drainage.
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