Common knowledge about diagnosis and treatment of common bile duct stones I. Definition Common bile duct stones are stones located in the common bile duct, which can be divided into primary bile duct stones and secondary bile duct stones from the gallbladder or intrahepatic bile duct according to their origin. Clinical manifestations The clinical manifestations of common bile duct stones and the mildness, severity and danger of the disease depend entirely on the degree of stone obstruction and the presence of biliary tract infection. Paroxysmal epigastric pain, chills, fever and jaundice (Charcot’s triad) are the typical manifestations of secondary biliary tract infection due to stone obstruction in the common bile duct. Due to the retention of bile, the common bile duct is dilated, and the contraction of the gallbladder and peristalsis of the common bile duct can cause the stone to be displaced or eliminated. Once the obstruction is lifted and the bile flows, the symptoms are relieved. However, if the biliary tract infection is serious and complicated by acute obstructive septic cholangitis, the condition develops rapidly, and nearly half of the patients soon appear irritability, delirium or drowsiness, coma and infectious shock manifestations such as decreased blood pressure and acidosis, etc. If not treated in time, death often occurs within 1-2 days or even within a few hours due to circulatory failure. Diagnosis The diagnosis of common bile duct stones should be considered in cases of extrahepatic obstructive jaundice, while the possibility that they are caused by malignant tumors or benign strictures should be excluded. The diagnosis of common bile duct stones can be based on clinical presentation and history. Liver function tests show obstructive jaundice, often accompanied by symptoms, abdominal pain, jaundice, chills and high fever (Charcot’s triad) suggesting cholangitis, which requires emergency management. Sometimes the common bile duct stones block the common opening of the biliopancreatic duct and cause acute pancreatitis, which is life-threatening. Endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography (PTC), CT, MRCP and ultrasonography can provide different levels of detailed and accurate information for diagnosis. ERCP can also be performed on tissue for pathological examination. The choice of test method depends on the skill of the physician and the hospital’s equipment, as well as the degree to which each individual is an advocate of a particular technique. Ultrasound and CT, MRCP can reliably detect bile duct dilatation due to obstruction. ERCP is now recognized by the academic community as the gold standard for the diagnosis of common bile duct stones. IV. Treatment Common bile duct stones are the most common cause of extrahepatic obstructive jaundice, severe or fatal infections (e.g. cholangitis), pancreatitis or chronic liver disease. Bacterial infection soon develops in the obstructed bile ducts and the resulting cholangitis is an important focus of bacteremia and systemic infection and should be treated with early surgery or endoscopic biliary decompression. Although the clinical presentation of patients with common bile duct stones varies, stones are an important cause of the disease and must be removed once identified. Antibiotic therapy is required for patients with coexisting cholangitis prior to surgical or endoscopic stone removal. Transendoscopic papillary sphincterotomy (EST) is the application of ERCP in the treatment. This treatment involves the use of a high-frequency electric knife electrocautery to cut open the duodenal papilla and remove the stone directly using a metal extraction mesh basket. The success rate of endoscopic removal of common bile duct stones in our hepatobiliary surgery department is 98.6%. According to the relevant literature, the incidence of death and complications caused by EST are 0.3-1.0% and 3%-7%, respectively, which are lower than when treated surgically. Acute complications of EST include bleeding, pancreatitis, perforation and cholangitis. For elderly patients with common bile duct stones and those who have undergone cholecystectomy, EST is indeed a good minimally invasive treatment method if physical conditions allow. When these patients present with acute cholangitis or gallstone pancreatitis, endoscopic bile duct decompression can have the same effect as surgical decompression. In patients with stones obstructing the bile ducts and good gallbladder function, the best approach is to perform endoscopic sphincter medium or small incision lithotomy or papillary sphincter balloon dilation. If the stones are too large and difficult to remove, they can be removed after mechanical lithotripsy or laser or liquid electrolysis. If accompanied by gallbladder stones, the gallbladder stones should be treated electively.