Clinical manifestations: typical patients with common bile duct stones will have abdominal pain, chills and hyperthermia and jaundice (Charcot’s triad), and in severe cases, decreased blood pressure and neuropsychiatric symptoms (Reynolds’ quintuplet); on physical examination, yellow staining of the skin and sclera, right upper abdominal pressure, rebound pain, or muscle tension, sometimes Murphy’s sign (+) may be found; in the interictal period there may be no obvious symptoms or In the interictal period, there may be no obvious symptoms or signs; a few patients always have no obvious symptoms.
Laboratory tests: during the exacerbation phase, patients may have elevated white blood cells and neutrophils; liver function tests may show abnormalities, such as bilirubin, alkaline phosphatase, γ-glutamyltransferase, and serum transaminases may be elevated to varying degrees; in patients with severe cholangitis, electrolytes and renal function indicators may be abnormal; during the resting phase, the indicators may be normal.
Abdominal ultrasound: It can show the lesions of bile ducts and gallbladder inside and outside the liver, and is an indispensable first-line diagnostic imaging tool before ERCP; however, transabdominal ultrasound often cannot clearly show the lower part of the common bile duct, and the false-negative rate of diagnosing common bile duct stones is more than 30%, which can easily misdiagnose gas in the bile duct as stones, and cannot indicate whether there is stenosis in the lower part of the bile duct, therefore, ultrasound examination results alone are not enough to Therefore, ultrasound findings alone are not sufficient to decide whether ERCP treatment should be performed, and further imaging studies are recommended.
CT: The specificity of the diagnosis of bile duct stones is 84%-100% and the sensitivity 65%-93%; it can be used as a second-line diagnostic imaging tool for patients with negative ultrasound or in cases where further information about the liver, biliopancreatic and surrounding organs is needed.
MRI/MRCP: tomographic MRI examination has similar sensitivity and specificity as CT; MRCP can show the lesions of biliary and pancreatic ducts more visually and clearly, and has a higher diagnostic rate for stones ≥3 mm. MRCP has a high reference value for judging the condition and mastering indications and contraindications before ERCP.
Ultrasound endoscopy (EUS): EUS has a sensitivity of 84%~100% and a specificity of 96%~100% for the diagnosis of common bile duct stones, and has a similar diagnostic rate as ERCP, which has a higher diagnostic accuracy for small stones in the bile duct and is relatively safe for patients who have not yet been clearly diagnosed.
ERCP: The sensitivity of diagnosing bile duct stones ranges from 79% to 100%, and the specificity from 87% to 100%. Since ERCP is invasive and risky, patients often need to be hospitalized, the cost is higher, and they also need to bear the risk of operation failure and complications, therefore, in principle, it is not recommended to perform purely diagnostic ERCP.
Diagnosis of bile duct stones: in patients with suspicious symptoms/signs, the diagnosis is gradually established through first- and second-line tests, and then a treatment plan is developed; in cases of suspected bile duct stones, less invasive and more diagnostic imaging tests, such as MRCP or EUS, are recommended, and the implementation of diagnostic ERCP is not recommended; if conditions permit, it is recommended to routinely undergo MRCP before ERCP.
Case selection
ERCP should not be used as a first-line diagnostic tool, and purely diagnostic ERCP should be avoided as much as possible; ERCP should be performed with caution in the absence of any imaging evidence of clinically suspected bile duct stones; ERCP is recommended only for the treatment of diagnosed cases of common bile duct stones, for stone removal or bile duct drainage. Patients with diagnosed common bile duct stones, with or without symptoms, should be treated in principle for a limited period of time if not specifically contraindicated; ERCP, laparoscopic surgery, and open surgery can be used for treatment, and the most beneficial treatment modality should be selected based on the patient’s condition, the technical conditions of the unit, and the experience of the operator. It is recommended to establish a multidisciplinary discussion mechanism to develop a suitable treatment plan for the patient.
Patients with pure extrahepatic bile duct stones and whose gallbladder has been removed are generally considered first for ERCP/EST bile duct extraction if there are no special contraindications.
Patients with common bile duct stones combined with gallbladder stones can be treated in three ways: (1) ERCP bile duct extraction + laparoscopic cholecystectomy; (2) laparoscopic cholecystectomy and biliary exploration surgery; (3) open cholecystectomy with biliary exploration surgery; depending on the patient and the treatment unit.
In patients with common bile duct stones, if the gallbladder is still in place and there are no stones, and if the gallbladder function is basically normal, they should be managed by preserving the function of the sphincter of Oddi as much as possible.
In common bile duct stones, when the patient has a T-tube in place, in principle, the first consideration is to apply choledochoscopy to retrieve the stone via the T-tube sinus tract.
Common bile duct stones with acute cholangitis are not a contraindication to ERCP, and endoscopic intervention should be performed as early as possible on the basis of active supportive therapy; EST extraction is feasible, or nasobiliary ducts or stents can be left in place for biliary decompression and drainage first, and further treatment will be performed after the condition is stabilized.
Primary intrahepatic bile duct stones are, in principle, not an indication for ERCP. The presence of a large number of stones in several branches of the intrahepatic bile duct, especially in combination with hepatic duct stenosis, ERCP is often unable to release the hepatic duct stenosis and completely remove the stones, and EST is generally not recommended. intra- and extrahepatic bile duct stones, if intrahepatic stones cannot be removed, EST should be performed with caution, unless the extrahepatic bile duct stones have caused bile duct obstruction/infection.
If there is a long stenosis in the lower part of the common bile duct, especially in the pancreatic segment, the stenosis cannot be released even after EST or stenosis dilatation, and it is often difficult to remove the stone, and the stone is prone to recurrence, so such cases are not suitable for ERCP to remove the stone.
For congenital common bile duct cyst combined with stones, EST alone is generally not recommended for stone extraction.
Acute Biliary Pancreatitis (ABP), if it meets the index of severe disease or is accompanied by cholangitis or obstructive jaundice, emergency ERCP should be performed as early as possible (<72h), and EST extraction or bile duct drainage should be performed, which can reduce complications and mortality; light ABP can be treated conservatively first, and appropriate endoscopic treatment can be taken at a later stage after the condition is stabilized.
In cases of large or large number of common bile duct stones, or those with limited technical equipment and unable to remove stones, EST should be performed with caution; bile duct drainage (endoscopic or radiological intervention) can be considered if surgery is contraindicated.
Patients with cirrhosis and portal hypertension are prone to serious complications when performing ERCP and should be performed with caution.
After gastrointestinal reconstruction: ERCP/stone extraction in patients with Bi-II gastrectomy is more difficult and risky, and it is recommended to be operated by experienced endoscopists; in cases of gastrointestinal Roux-en-Y anastomosis, pancreaticoduodenectomy, bile duct jejunostomy Roux-en-Y anastomosis (bile duct has been transected), although there are a few reports of successful implementation of ERCP by applying balloon type small bowel scope, it is extremely technically In principle, other treatments should be considered first.
Pediatrics: Pediatrics is not a contraindication to ERCP, but the indications should be strictly controlled. Pediatric patients who cannot cooperate should be performed under anesthesia and it is recommended that they be operated by an experienced endoscopist. Generally children over 3 years of age can be operated with an adult duodenoscope, or a pediatric-specific endoscope is available with limited supporting instruments. Although it is generally safe to perform EST in young patients, sphincter function should be preserved/partially preserved as much as possible when conditions permit, and radiological protection and vital signs should be monitored.
Pregnant women: ERCP is risky and technically difficult to perform during pregnancy and should only be considered when bile duct stones cause cholangitis or pancreatitis; if possible, the operation should be postponed until mid-pregnancy (4-6 months), and radiological protection and vital signs monitoring should be performed for the pregnant woman and fetus. Pregnant women with pregnancy complications, such as placental abruption, fetal membrane rupture, convulsions or preterm abortion, should be considered contraindicated.