Endoscopic Management of Common Bile Duct Stones

Abstract

Gallstone disease is one of the most common reasons for hospital admission. CBD stones are classified in primary and secondary stone on the basis of the site of origin. Clinical presentation varies from asymptomatic to life threatening conditions such as acute biliary pancreatitis and cholangitis. Patients are categorized in low, intermediate and high risk of choledocholithiasis using clinical, biochemical and imaging factors. Patients with low risk of choledocholithiasis should receive cholecystectomy without further evaluation whileit has been recognized the importance of sequential use of EUS-ERCPin patients with intermediate risk of choledocholithiasis to triage patients in need of treatment. Patients with high risk of choledocholithiasis should receive ERCP before performing cholecystectomy although randomized clinical trial showed no benefit for preoperative ERCP over operative cholangiography and common duct exploration. Patients should be received an informed consent and antiplatelet and anticoagulation treatment should discontinued for the appropriate drug-specific interval in according to the recent guideline. Routine administration to all patients undergoing to ERCP is considered unnecessary unless cholangitis or immunosoppression is present or biliary drainage is predicted to be incomplete. All patients undergoing to ERCP should be administered prophylactic drugs such as rectal indomethacin or diclofenac because of consistently reduced risk of post ERCP pancreatitis according to several meta-analysis and ESGE guideline. Endoscopic treatment is based on selective incannulation of the CBD and performing adequate endoscopic sphincterotomy. In case of failed biliary access several reasonable options could be chosen. CBD stone can be removed with either a basket or a balloon catheter in 85-90% of cases and the choice of the better device depends on common bile duct and stone size. Approximately 10-15% of biliary stone are difficult to extract and several technique, such as EPBD, PBSD and ML can be used. Alternative modality for the fragmentation of refractory CBD stone are intraductal lithotripsy (eg. Laser or Electrohydraulic lithotripsy) and ESWL. Mirizzi syndrome is usually treated by surgery although although there have been case reports of endoscopic removal.Intrahepatic stones are treated by dormia basket on guidewire after balloon dilation if stricture is present or cholangioscopy with intraductal lithotripsy, per-oral cholangioscopic lithotripsy (POCSL) or percutaneous transhepatic cholangioscopy lithotripsy (PTCSL) and surgical resection (Hepatectomy). POCSL and PTCSL are hindered by high rates of stone recurrence. Biliary stenting as definitive treatment of difficult bile duct stone should be reserved for patients with short life expectancy.A review of case series suggest that BS is a safe and effective treatment for common bile duct stone in the pregnant patient but may be associated with higher risk of post ERCP pancreatitis than in the general population.