Management of Biliary Lithiasis

Sean Bhalla, MD

Ryan Law, DO

Over 20 million Americans are estimated to have gallbladder disease.¹ Choledocholithiasis has been estimated to be present in 10% to 20% of individuals with symptomatic gallstones.² Biliary lithiasis can be associated with acute cholangitis and/or acute biliary pancreatitis. Choledocholithiasis often requires prompt endoscopic treatment prior to surgical cholecystectomy in symptomatic biliary lithiasis or cholangitis, to aid in resolution of pancreatitis, or to minimize subsequent episodes of pancreatitis. Nearly all bile duct stones can be treated endoscopically using various methods. Small bile duct stones can easily be extracted via sphincterotomy in conjunction with balloon or basket extraction. Large bile duct stones, defined as a stone ≥1.5 cm in diameter, can be more challenging to extract. Multiple procedures and techniques may sometimes be required in the treatment of larger stones. The American Society for Gastrointestinal Endoscopy (ASGE) provides an up-to-date guideline of endoscopic management of choledocholithiasis, but does not provide explicit guidelines or technical interventions needed for stone extraction.³ This chapter will outline and review available techniques for removal of bile duct stones.

ABSOLUTE CONTRAINDICATIONS

1. Refer to Chapter 5 on Basic Upper Endoscopy
2. Refer to Chapter 25 on Basic ERCP

RELATIVE CONTRAINDICATIONS

1. Coagulopathy, INR >1.5
2. Baseline platelet count <50,000/mm
3. Refer to Chapter 25 on Basic ERCP

EQUIPMENT

Duodenoscope and accompanying tower/processor/monitor
CO₂ insufflator with full canister or wall attachment
Guidewire (minimum 270 cm length)
Sphincterotome (Needle knife papillotome should be available for freehand precut.)
Stone retrieval basket and/or extraction balloon
Dilating balloons and inflation device (size range 8 mm up to 20 mm)
Mechanical lithotriptor
Digital, single-operator cholangioscopy with electrohydraulic lithotriptor and accessories (SpyGlass DS; Boston Scientific, Marlborough, MA)
Fluoroscopy
Water-soluble contrast
Leaded aprons for radiation safety
Radiation dosage badges for personnel

PREPROCEDURE

1. Patient should be NPO at least 6 hours to procedure.
2. Patients on anticoagulants and antiplatelet agents should stop or alter their medication after discussion with the prescribing physician (if unable to stop anticoagulation, consider balloon sphincteroplasty) (see Chapter 4 on Anticoagulant and Antiplatelet Agents).
3. Obtain standard preoperative consent by the endoscopist and anesthesiologist outlining possible risks, benefits, and alternative methods of treatment.
4. Position patient per endoscopist preference (i.e., prone, supine, or left lateral).
5. ERCP is generally performed under anesthesia assistance.
6. Consider a single dose of indomethacin 100 mg per rectum to reduce the risk of post-ERCP pancreatitis, if no contraindications are identified.
7. Consider preprocedure initiation of intravenous fluids (specifically lactated Ringer’s solution) with continuation to the postprocedure setting to reduce the risk of pancreatitis.

PROCEDURE

Techniques for Stone Extraction

Balloon Sphincteroplasty + Balloon/Basket Extraction

Balloon sphincteroplasty (without sphincterotomy) was initially described for removal of small stones with goal of preserving the sphincter of Oddi.⁴ This technique may be particularly useful in patients with surgically altered anatomy (e.g., Billroth II gastrojejunostomy⁵), periampullary diverticulum, coagulopathy, thrombocytopenia, and/or need for ongoing anticoagulation where sphincterotomy is less desirable. It is important to note that there have been reports increased adverse event rates such as post-ERCP pancreatitis with sphincteroplasty.

1. Cannulate the bile duct and pass a guidewire into the biliary tree (see Chapter 25 on Basic ERCP).
2. Dilating balloon (<12 mm diameter) is passed over the guidewire and placed across the ampullary orifice.
3. Inflate the balloon to the desired diameter and pressure using iodinated contrast.
4. Hold the balloon in place across the papilla for at least 30 seconds.
5. Adequate dilation has been achieved when the waist of the balloon is no longer visible.
6. Deflate the balloon.
7. Evaluate the dilation to ensure the stone can be extracted (dilation can be repeated).
8. If necessary, balloon or basket extraction can be used to remove stones.

Sphincterotomy + Balloon/Basket Extraction (Video 27.1)

Sphincterotomy is a commonly performed technique in ERCP. It is important as it improves the ability for biliary stone removal and may facilitate additional endotherapy (i.e., stent placement, dilation, etc.).