Choledocholithiasis and obstructive jaundice

01OverviewDefinition, clinical context and the essential points that orientate the chapter.

Choledocholithiasis occurs when stones migrate from the gallbladder, form primarily within the duct or remain after cholecystectomy. Obstruction raises conjugated bilirubin and cholestatic enzymes, reduces bile reaching the gut and predisposes to bacterial ascent. The clinical spectrum extends from incidental imaging findings to painful jaundice, gallstone pancreatitis and life-threatening cholangitis. A stone can move, so symptoms, liver chemistry and imaging may change rapidly.

Obstructive jaundice is a syndrome rather than a stone diagnosis. Malignant causes become more likely with painless progressive jaundice, weight loss, a palpable non-tender gallbladder or a new duct stricture, but cancer and stones can coexist. Drug injury, viral hepatitis and haemolysis can mimic pieces of the biochemical picture. The safest assessment defines whether bilirubin is conjugated, whether ducts are dilated, where obstruction lies and whether infection or organ dysfunction is already present.

The investigation sequence should minimise procedural harm. Ultrasound identifies stones in the gallbladder and duct calibre. MRCP maps ducts non-invasively, and EUS detects small distal stones or periampullary lesions when uncertainty remains. ERCP provides sphincterotomy, extraction, drainage and sampling but must have a therapeutic or carefully justified tissue objective. After duct clearance, treating the gallbladder reduces recurrence; stenting without reliable recall creates preventable cholangitis.

Key points

Common-duct stones may cause biliary pain, fluctuating jaundice, pruritus, dark urine and pale stool, or may be discovered through duct dilatation and cholestatic blood tests.
Fever or rigors with jaundice and abdominal pain suggests infected obstruction; hypotension or confusion signifies severe cholangitis and demands emergency antibiotics plus drainage planning.
A cholestatic pattern raises obstruction but does not identify its cause: stones, pancreatic or biliary malignancy, benign stricture, pancreatitis and primary sclerosing cholangitis remain alternatives.
NICE uses ultrasound and liver tests first, then MRCP when a stone is not seen but the duct is dilated and/or liver results are abnormal; consider EUS if MRCP remains uncertain.
ERCP is principally therapeutic because it can cause pancreatitis, bleeding, perforation and infection; stable diagnostic uncertainty belongs with MRCP or EUS rather than reflex cannulation.
Confirmed common-duct stones require bile-duct clearance surgically or with ERCP before or during laparoscopic cholecystectomy under NICE CG188.
A falling bilirubin may reflect stone passage, intermittent obstruction or partial drainage and does not by itself exclude retained calculi or malignancy.
Every biliary stent needs a documented indication, type, insertion date, planned removal or exchange date, warning symptoms and an accountable clinical team.

02AetiologyUnderlying causes, associations and risk factors, with why each one matters.

Migrated gallstones

Most common-duct stones originate in the gallbladder and migrate through the cystic duct, intermittently or persistently obstructing bile flow.

Primary duct stones and stasis

Stones can form within dilated or infected ducts, particularly with altered biliary anatomy, strictures or impaired drainage.

Non-stone obstruction

Pancreaticobiliary malignancy, benign stricture, pancreatitis, PSC and blocked stents are important alternative causes of an obstructive-jaundice phenotype.

03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.

1
Duct occlusion
An impacted stone prevents bile reaching the duodenum, raises upstream pressure and dilates intrahepatic or extrahepatic ducts.
2
Conjugated bilirubin retention
Water-soluble bilirubin and bile salts enter blood and urine, producing jaundice, dark urine, pale stool and pruritus.
3
Inflammatory complications
Stagnant pressurised bile permits ascending infection, while ampullary obstruction can impair pancreatic drainage and trigger pancreatitis.

04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.

Intermittent stone obstruction

Colicky or steady biliary pain with fluctuating jaundice and liver enzymes can reflect a mobile common-duct stone, even when later ultrasound is normal.

Complete cholestasis

Deepening jaundice, pruritus, dark urine, pale stool and fat malabsorption suggest sustained reduction in bile flow and require prompt anatomical definition.

Ascending infectionRed flag

Fever, rigors and inflammatory deterioration in an obstructed patient indicate cholangitis; shock, delirium or organ failure require immediate source-control escalation.

Gallstone pancreatitisRed flag

Severe epigastric pain radiating to the back, vomiting and raised lipase may follow transient ampullary obstruction and changes urgency and definitive gallbladder planning.

Possible malignant obstruction

Progressive painless jaundice, unintentional weight loss, anorexia, a fixed stricture or pancreatic, gallbladder or biliary mass needs urgent HPB cancer assessment rather than repeated stone treatment.

05InvestigationsWhat to request, why it matters and how to interpret it.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
Fractionated bilirubin and liver profileFirst step
Why
Confirm conjugated cholestasis, identify concurrent hepatic injury and establish a trajectory before intervention.
Interpretation and limitations
Alkaline phosphatase and GGT often rise, but early stone passage can cause a sharp aminotransferase increase; trends localise poorly and never replace imaging.
02
Abdominal ultrasound
Why
Assess gallbladder stones, intrahepatic and extrahepatic duct dilatation and a visible proximal obstructing lesion.
Interpretation and limitations
Dilatation supports mechanical obstruction but may be absent early, intermittent or after previous surgery; direct distal-duct sensitivity is limited by bowel gas.
03
MRCP
Why
Provide a non-invasive map of stone location, level of obstruction, strictures and intrahepatic duct anatomy.
Interpretation and limitations
A filling defect supports choledocholithiasis, while an abrupt or irregular stricture raises malignancy; very small ampullary stones may remain occult.
04
Endoscopic ultrasound
Why
Resolve persisting suspicion after non-diagnostic MRCP and assess distal duct, ampulla and adjacent pancreatic tissue.
Interpretation and limitations
EUS can identify tiny calculi and masses without instrumenting the duct, but positive findings still require a therapeutic or tissue-acquisition plan.
05
FBC, CRP, cultures and lactate
Why
Detect infection, bacteraemia and organ hypoperfusion when cholangitis is possible.
Interpretation and limitations
Inflammation plus obstruction increases drainage urgency. Immunosuppression can blunt leucocytosis, and antibiotics must not wait for culture positivity.
06
Contrast CT staging study
Why
Investigate suspected tumour, complications or an alternative abdominal cause and define vascular or metastatic anatomy.
Interpretation and limitations
CT complements rather than replaces detailed duct imaging; obtain cancer-protocol imaging before stenting when the stable clinical situation permits.

06Differential diagnosisRealistic alternatives and the features that help distinguish them.

Pancreaticobiliary malignancy

Progressive painless jaundice, weight loss, a mass or irregular stricture favours cancer and requires staging before potentially disruptive drainage.

Hepatocellular jaundice

Marked hepatocellular enzymes, exposure history and non-dilated ducts suggest hepatitis or DILI, although early obstruction can temporarily resemble this pattern.

Unconjugated hyperbilirubinaemia

Anaemia, reticulocytosis or an isolated unconjugated bilirubin rise indicates haemolysis or impaired conjugation rather than mechanical bile-duct obstruction.

07ManagementImmediate care, first-line treatment, alternatives and escalation.

01StableSuspected duct stoneFirst stepCholestatic tests or duct dilatation suggests choledocholithiasis without fever, shock or organ dysfunction.

1Take a focused malignancy and gallstone history, examine for sepsis and send liver, renal, inflammatory, coagulation and pancreatic blood tests.
2Perform transabdominal ultrasound, then use MRCP under the NICE sequence when the stone is unseen but biochemical or duct evidence persists.
3Request specialist EUS if MRCP cannot answer a clinically credible question, avoiding ERCP undertaken solely to look.
4For a confirmed stone, coordinate duct clearance and laparoscopic cholecystectomy through the local surgical-endoscopy service.

02InfectedObstruction with cholangitisFever, rigors or systemic deterioration accompanies evidence of a blocked biliary system.

1Begin ABCDE and sepsis care, obtain blood cultures when this is immediate, and administer guideline-concordant intravenous antibiotics without harmful delay.
2EscalationContact the emergency ERCP and senior HPB teams early because drainage, not antimicrobial escalation alone, controls the infected obstructed source.
3Use endoscopic drainage when feasible, with percutaneous or surgical alternatives selected if ERCP is unavailable, unsuccessful or anatomically unsuitable.
4After stabilisation, define and treat the cause, remove temporary devices on schedule and arrange gallbladder surgery when stones originated there.

03StricturePossible malignant jaundiceProgressive painless cholestasis, weight loss or a fixed biliary narrowing makes cancer plausible.

1Arrange urgent HPB pathway review and high-quality cross-sectional imaging before duct instrumentation whenever infection and physiology allow.
2Discuss the imaging at specialist MDT to determine whether the lesion appears pancreatic, gallbladder, intrahepatic, perihilar, distal biliary or benign.
3Let the MDT choose tissue route and drainage target because poorly planned biopsy or stenting can compromise staging and future surgery.
4Treat distressing pruritus, malnutrition, coagulopathy and cholangitis while ensuring results and the next decision are communicated promptly.

Key medicines and prescribing safety3 treatments · regimens, roles and cautions

Reduces bacterial burden during resuscitation and urgent relief of an infected obstruction.

Intravenous biliary-sepsis antibiotics

Use the current local cholangitis regimen at BNF-adjusted adult doses, modified for allergy, renal function, cultures and recent antimicrobial exposure.

Antibiotics cannot substitute for drainage; broad therapy should be reviewed after cultures and source control to reduce toxicity and resistance.

May reduce bile-acid-associated itch while the obstructive cause is being treated.

Cholestyramine for obstructive pruritus

Use a current BNF oral regimen in selected stable patients, separated by several hours from other medicines to limit binding interactions.

It is not emergency decompression, may worsen constipation and can impair absorption of medicines and fat-soluble vitamins; seek specialist advice in complete obstruction.

Corrects a vitamin-K-responsive coagulopathy caused by prolonged cholestasis before an indicated procedure.

Vitamin K replacement when deficient

Choose oral or parenteral phytomenadione using current BNF and local peri-procedural guidance after reviewing the cause and urgency.

Not all INR elevation is nutritional, and correction must not delay drainage in life-threatening cholangitis; anticoagulant reversal follows separate protocols.

08ComplicationsImportant consequences, why they occur and why they matter clinically.

Ascending cholangitis

Infected obstruction causes fever, rigors, pain and jaundice, progressing to hypotension, confusion and multiorgan sepsis without drainage.

Gallstone pancreatitis

A stone transiently or persistently obstructing the ampulla can activate pancreatic inflammation, with organ failure or necrosis in severe disease.

Persistent cholestatic injury

Prolonged blockage causes pruritus, fat malabsorption, coagulopathy and secondary biliary fibrosis, while an untracked stent can re-obstruct or infect.

09Monitoring and follow-upTreatment response, safety checks and longer-term review.

Trend bilirubin, alkaline phosphatase, renal function, inflammatory markers and clinical jaundice after extraction or drainage.
Observe after ERCP for new abdominal pain, vomiting, haemodynamic change, bleeding, fever or perforation under the unit protocol.
Confirm documented stone clearance rather than inferring success from symptom improvement or a falling bilirubin alone.
Maintain a stent register entry with due date, named clinician and route for urgent review if fever or jaundice recurs.
For malignant or indeterminate strictures, ensure imaging, cytology or histology and MDT outcomes remain linked across hospitals.

10Special situationsVariants, exceptions and circumstances that change the usual approach.

Ducts may not dilate

Early, intermittent or small-calibre obstruction can produce jaundice before sonographic dilatation becomes obvious.

ERCP should do something

A clear plan for extraction, drainage or sampling helps justify exposing the patient to this high-risk procedure.

Biochemistry can fluctuate

A migrating stone may generate dramatic transient aminotransferase change and later leave a quieter cholestatic pattern.

Cancer and stones coexist

Finding a calculus does not explain progressive weight loss or a dominant stricture without adequate staging review.

Stents create future risk

Occlusion, migration and infection make a reliable recall system part of the original procedure, not optional administration.

11Common pitfallsFrequent interpretation and management errors.

01
Assuming painless jaundice is a stone diagnosis without cancer assessment.
02
Sending a stable patient straight to diagnostic ERCP before MRCP or EUS.
03
Dismissing choledocholithiasis after one normal bilirubin measurement.
04
Delaying emergency drainage while repeatedly changing antibiotics in cholangitis.
05
Biopsying or stenting an indeterminate hilar lesion before HPB planning.
06
Leaving a plastic biliary stent without a traceable exchange plan.