Modern Management of Common Bile Duct Stones

It is imperative for gastroenterologists to understand the different formations of bile duct stones and the various medical treatments available. To minimize the complications of endoscopic retrograde cholangiopancreatography (ERCP), it is critical to appropriately assess the risk of bile duct stones before intervention. Biliary endoscopists should be comfortable with the basic techniques of stone removal, including sphincterotomy, mechanical lithotripsy, and stent placement. It is important to be aware of advanced options, including laser and electrohydraulic stone fragmentation, and papillary dilatation for problematic cases. The timing and need for ERCP in those who require a cholecystectomy is also a consideration.

Key points

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Given lack of efficacy relative to endoscopic retrograde cholangiography (ERCP), pharmacologic therapy for bile duct stones should be reserved for patients who are not candidates for therapeutic procedures.
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ERCP should be performed only if there is a high suspicion of bile duct stones; imaging studies for confirmation should be performed if there is intermediate suspicion, to minimize complications associated with ERCP.
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ERCP with sphincterotomy, mechanical lithotripsy, and stent placement may be used to remove most bile duct stones; biliary endoscopists should be adept at precut techniques and the removal of impacted baskets from the duct.
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Intraductal laser and electrohydraulic lithotripsy may be used to fragment most large bile duct stones, and their use will likely become more widespread with the introduction of single-operator cholangioscopes.
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Balloon dilatation after endoscopic sphincterotomy is an effective technique for removal of large bile duct stones.
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The approach to patients with concomitant bile duct stones and cholelithiasis depends on available laparoscopic surgical and biliary endoscopic expertise.