Choledocholithiasis is a medical condition defined by the presence of gallstones within the common bile duct (CBD). These stones may originate in the gallbladder (secondary choledocholithiasis) or form primarily within the bile ducts (primary choledocholithiasis). This condition can lead to biliary obstruction, cholangitis and potentially life-threatening complications if not promptly recognized and treated. 

Gallstone disease is one of the most common gastrointestinal disorders worldwide. While gallstones are frequently asymptomatic within the gallbladder, their migration into the common bile duct can produce significant morbidity. Choledocholithiasis is of clinical importance because of its potential to cause obstructive jaundice, pancreatitis and ascending cholangitis—conditions that require urgent medical attention. 

Choledocholithiasis refers to the presence of gallstones within the common bile duct, the structure that conveys bile from the liver and gallbladder to the duodenum. The stones obstruct the normal flow of bile, leading to biliary stasis, ductal dilatation, and potential infection or inflammation. 

Types of Choledocholithiasis: 

• Secondary choledocholithiasis: Stones that form in the gallbladder and migrate into the CBD. This is the most common type. 
• Primary choledocholithiasis: Stones that form de novo within the bile ducts, often associated with bile stasis, infection, or anatomical abnormalities. More common in regions where hepatolithiasis is endemic (e.g., East Asia). 

Epidemiologically, choledocholithiasis occurs in about 10–15% of individuals with gallstones. The risk increases with age and is more frequent in patients with large or multiple gallstones. 

The clinical significance of choledocholithiasis lies not only in its immediate complications but also in the diagnostic and therapeutic challenges it presents. In some cases, the stones may remain silent within the bile duct for months or even years before symptoms develop, which can lead to delays in diagnosis. Furthermore, recurrent episodes of biliary obstruction can lead to chronic inflammation of the bile ducts, contributing to long-term damage such as biliary stricture formation or secondary biliary cirrhosis. 

In resource-limited settings, primary choledocholithiasis may present at an advanced stage due to delayed access to healthcare or limited imaging availability, making timely intervention more difficult. This highlights the importance of early recognition and appropriate referral to specialized centers where advanced endoscopic and surgical options are available. 

Choledocholithiasis develops due to the formation or migration of stones into the bile ducts. The contributing factors include: 

Secondary choledocholithiasis 

• Migration of gallstones from the gallbladder (typically cholesterol or mixed stones) 

Primary choledocholithiasis 

• Chronic biliary infection (e.g., with E. coli, Klebsiella) 

• Biliary stasis from strictures or sphincter of Oddi dysfunction 

• Anatomical anomalies (choledochal cysts, biliary diverticula) 

• Parasitic infections (e.g., Clonorchis sinensis, Opisthorchis) 

Risk factors 

• Gallstones (cholelithiasis) 

• Age >60 years 

• Female sex (though less pronounced than with gallstones) 

• Previous cholecystectomy (risk of retained or recurrent stones) 

• Hemolytic disorders (pigment stone formation) 

Additional factors contributing to choledocholithiasis include metabolic disturbances that predispose to stone formation, such as obesity, metabolic syndrome, and rapid weight loss following bariatric surgery. These conditions alter bile composition, increasing the risk of cholesterol supersaturation and crystal nucleation. In regions with endemic parasitic infections, chronic infestation leads to recurrent cholangitis and bile stasis, which promotes stone formation and recurrent ductal obstruction. 

Interestingly, certain medications (such as ceftriaxone, octreotide, or hormonal therapies) have been associated with biliary sludge or stone formation, potentially increasing the risk of choledocholithiasis in susceptible individuals. Understanding these risk factors helps guide preventive strategies and management decisions, particularly in high-risk populations. 

In choledocholithiasis, obstruction of bile flow by stones leads to: 

• Increased intraductal pressure 

• Biliary tree dilatation 

• Impaired bile drainage and stasis 

• Risk of ascending infection (cholangitis) 

Prolonged obstruction can cause hepatocellular injury, cholestasis, and, if infection supervenes, severe sepsis. 

If a stone lodges at the ampulla of Vater: 

• Obstruction of the pancreatic duct may occur 

• Triggering acute gallstone pancreatitis 

Common symptoms: 

• Right upper quadrant or epigastric pain 

• Often intermittent, colicky  

• May radiate to the back or right shoulder 

• Jaundice  

• Often fluctuating  

• Dark urine, pale stools, pruritus 

• Fever  

• Suggests cholangitis if present with pain and jaundice (Charcot’s triad) 

Signs: 

• Icterus (yellowing of sclera) 

• RUQ tenderness 

• Hepatomegaly (occasionally) 

Classic triads and pentads: 

• Charcot’s triad: RUQ pain, fever, jaundice (suggestive of cholangitis) 

• Reynolds’ pentad: Charcot’s triad + hypotension + altered mental status (indicates severe cholangitis with sepsis) 

It is important to note that the clinical presentation of choledocholithiasis can vary widely, depending on the degree and duration of obstruction, as well as the presence of superimposed infection. In elderly or immunocompromised patients, classic symptoms such as pain or fever may be subtle or absent, with jaundice being the sole presenting feature. Additionally, some patients may exhibit nonspecific gastrointestinal complaints such as nausea, bloating, or indigestion, which can obscure the diagnosis. 

In rare cases, large stones can cause complete biliary obstruction, leading to progressive cholestatic liver injury, fat malabsorption, and deficiencies of fat-soluble vitamins (A, D, E, K) if left untreated over time. 

Laboratory tests 

• Elevated bilirubin (direct hyperbilirubinemia) 

• Elevated alkaline phosphatase (ALP) and gamma-glutamyl transpeptidase (GGT) 

• Mildly elevated AST, ALT 

• Leukocytosis (if cholangitis present) 

• Amylase/lipase (if pancreatitis suspected) 

Imaging studies 

• Ultrasound: First-line test; may show dilated bile ducts or stones in the CBD 

• Magnetic resonance cholangiopancreatography (MRCP): Non-invasive, high sensitivity 

• Endoscopic ultrasound (EUS): Excellent for detecting small stones 

• Endoscopic retrograde cholangiopancreatography (ERCP): Both diagnostic and therapeutic 

Other findings 

• Dark urine (bilirubinuria) 

• Pale stools 

Differential Diagnosis 

Conditions to consider: 

• Mirizzi syndrome (impacted gallstone causing external compression of the CBD) 

• Malignancy (cholangiocarcinoma, pancreatic head cancer) 

• Sclerosing cholangitis 

• Hepatitis 

• Gilbert’s syndrome (for isolated indirect hyperbilirubinemia) 

Supportive measures 

• IV fluids 

• Analgesia (avoid morphine due to sphincter of Oddi spasm) 

• Antibiotics (if cholangitis) 

Definitive treatment 

• ERCP with sphincterotomy and stone extraction (gold standard) 

• Laparoscopic common bile duct exploration (alternative in centers with expertise) 

• Cholecystectomy (elective if gallbladder present to prevent recurrence) 

Other options 

• Percutaneous transhepatic cholangiography (PTC) drainage (if ERCP fails or is contraindicated) 

For complex cases, such as those involving large or multiple stones, a combined approach using lithotripsy (mechanical, electrohydraulic, or laser) during ERCP may be required to fragment and extract the stones. In select cases, especially when ERCP is unsuccessful or contraindicated, surgical options such as open or laparoscopic choledochotomy may be considered, particularly in centers with appropriate expertise. 

Post-intervention care is crucial to prevent recurrence. This includes addressing modifiable risk factors such as obesity and dietary habits, as well as ensuring complete clearance of the bile duct. In patients undergoing cholecystectomy, intraoperative cholangiography may help identify unsuspected ductal stones, preventing retained stones postoperatively. 

• Ascending cholangitis 

• Acute pancreatitis 

• Secondary biliary cirrhosis (if obstruction is prolonged) 

• Hepatic abscess 

• Biliary stricture (from chronic inflammation or intervention) 

• Sepsis and multiorgan failure (in severe cholangitis) 

Recurrent choledocholithiasis can occur in up to 10% of patients even after cholecystectomy, particularly if underlying anatomical or functional abnormalities persist. This underscores the need for long-term follow-up in high-risk patients. Additionally, repeated instrumentation of the bile duct (e.g., during multiple ERCP procedures) may predispose to scarring and stricture formation, complicating future management. 

Severe cholangitis remains a life-threatening emergency, with mortality rates as high as 10–20% if timely biliary decompression is not achieved. Early recognition of Reynolds’ pentad — which indicates evolving septic shock — is vital to guide urgent intervention. 

The outcome largely depends on: 

• Timeliness of biliary drainage 

• Presence of cholangitis or pancreatitis 

• Comorbidities (e.g., advanced age, diabetes) 

With prompt intervention, most patients recover well. Delays in drainage for cholangitis can result in high mortality. 

• Early cholecystectomy in gallstone disease 

• Surveillance and timely intervention in high-risk groups (e.g., those with biliary anatomical abnormalities) 

• Parasite control in endemic regions 

• Avoid unnecessary delay in managing gallstones once symptomatic 

From a preventive standpoint, strategies such as dietary modification (reducing saturated fat intake, maintaining a healthy weight) and timely cholecystectomy for symptomatic gallstones play a key role in reducing the incidence of choledocholithiasis. In endemic regions, public health measures aimed at reducing parasitic infections contribute significantly to prevention efforts. 

For patients with known biliary abnormalities or high recurrence risk, regular imaging surveillance and prompt treatment of early biliary symptoms may help avert serious complications. 

Choledocholithiasis represents a critical intersection of gallstone disease and hepatobiliary emergencies. Although gallstones themselves may remain asymptomatic for years, their migration into the bile duct can precipitate severe illness. Early diagnosis through appropriate imaging and timely intervention, often via ERCP, are key to preventing complications and improving outcomes. 

Healthcare providers should maintain a high index of suspicion in patients with jaundice, RUQ pain, and fever. Multidisciplinary care involving gastroenterologists, surgeons, and radiologists ensures optimal management of this complex condition. 

1. Williams EJ, Green J, Beckingham I, et al. Guidelines on the management of common bile duct stones (CBDS). Gut. 2008;57(7):1004-1021. 

2. Freeman ML. Adverse outcomes of ERCP. Gastrointest Endosc. 2002;56(6 Suppl):S273-S282. 

3. ASGE Standards of Practice Committee. The role of endoscopy in the evaluation of suspected choledocholithiasis. Gastrointest Endosc. 2010;71(1):1-9. 

4. Liu CL, Fan ST, Lai EC, et al. Management of acute cholangitis: a multi-center study. Ann Surg. 2001;233(3):373-380.