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Cholangiolithiasis – Gallstones in the Bile Duct

Cholangiolithiasis refers to the presence of gallstones within the bile ducts. It can cause pain, jaundice, and serious complications such as bile duct inflammation.

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Things worth knowing about "Cholangiolithiasis"

Cholangiolithiasis refers to the presence of gallstones within the bile ducts. It can cause pain, jaundice, and serious complications such as bile duct inflammation.

What is Cholangiolithiasis?

Cholangiolithiasis is a medical condition in which gallstones are present within the bile ducts, including the common bile duct (choledochus) and the intrahepatic bile ducts. These stones can obstruct the flow of bile and lead to serious complications. A distinction is made between primary stones, which form directly within the bile ducts, and secondary stones, which have migrated from the gallbladder into the bile ducts.

Causes

Several factors can contribute to the development of cholangiolithiasis:

Migration of gallstones from the gallbladder into the bile duct (most common cause)
Primary stone formation within the bile duct, often related to bile salt changes or infections
Bile duct infections caused by bacteria or parasites
Anatomical changes to the bile ducts, for example following surgery
Hemolytic diseases that increase bilirubin levels in the bile

Symptoms

Cholangiolithiasis may be asymptomatic but often presents with the following symptoms:

Biliary colic: cramping pain in the upper right abdomen, often triggered by fatty meals
Jaundice (icterus): yellowing of the skin and eyes due to bile obstruction
Dark urine and pale stools indicating impaired bile flow
Fever and chills in the presence of bile duct inflammation (cholangitis)
Nausea and vomiting

Diagnosis

Several diagnostic approaches are used to identify cholangiolithiasis:

Blood tests: elevated liver enzymes (e.g., bilirubin, alkaline phosphatase, GGT) suggest bile obstruction
Ultrasound (sonography): the first-line imaging method, detecting gallstones and bile duct dilation
Magnetic Resonance Cholangiopancreatography (MRCP): a non-invasive MRI-based visualization of the bile ducts
Endoscopic Retrograde Cholangiopancreatography (ERCP): an invasive technique that allows simultaneous diagnosis and treatment
Endoscopic Ultrasound (EUS): high-resolution imaging from within the gastrointestinal tract

Treatment

Treatment of cholangiolithiasis depends on the severity of the condition and the overall health of the patient:

Endoscopic Therapy

ERCP with sphincterotomy is the preferred treatment approach. The bile duct is visualized endoscopically, the sphincter of Oddi is opened, and the stones are mechanically removed or fragmented.

Medical Treatment

In cases of accompanying cholangitis, antibiotics are administered. Ursodeoxycholic acid may be used to dissolve cholesterol stones in mild cases, although this is rarely sufficient for stones located in the bile ducts.

Surgical Therapy

If endoscopic removal is not possible, surgical bile duct exploration (choledochotomy) may be necessary. Simultaneous removal of the gallbladder (cholecystectomy) is often performed to prevent recurrent stone migration.

Complications

If left untreated, cholangiolithiasis can lead to serious complications:

Cholangitis: bacterial infection of the bile ducts presenting with fever, jaundice, and abdominal pain (Charcot triad)
Biliary pancreatitis: inflammation of the pancreas caused by stone blockage
Liver abscesses
Biliary cirrhosis in chronic cases
Sepsis in severe cholangitis

References

Lammert F. et al. - Gallstones. Dtsch Arztebl Int. 2016;113(9):148-158. DOI: 10.3238/arztebl.2016.0148
European Association for the Study of the Liver (EASL) - Clinical Practice Guidelines on the prevention, diagnosis and treatment of gallstones. Journal of Hepatology. 2016;65(1):146-181.
Greenberger N.J., Paumgartner G. - Diseases of the Gallbladder and Bile Ducts. In: Harrison's Principles of Internal Medicine, 20th Edition. McGraw-Hill, 2018.

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