Synopsis
Recognise common-duct stones and the broader obstructive-jaundice differential, choose ultrasound, MRCP, EUS and ERCP for the right questions, and prevent untreated cholangitis or unowned stents.
- 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.
Key red flags
Fever, rigors and inflammatory deterioration in an obstructed patient indicate cholangitis; shock, delirium or organ failure require immediate source-control escalation.
Investigation priorities
Confirm conjugated cholestasis, identify concurrent hepatic injury and establish a trajectory before intervention.
Management branches
Cholestatic tests or duct dilatation suggests choledocholithiasis without fever, shock or organ dysfunction.
- Take a focused malignancy and gallstone history, examine for sepsis and send liver, renal, inflammatory, coagulation and pancreatic blood tests.
- Perform transabdominal ultrasound, then use MRCP under the NICE sequence when the stone is unseen but biochemical or duct evidence persists.
Key medicines
Intravenous biliary-sepsis antibioticsUse the current local cholangitis regimen at BNF-adjusted adult doses, modified for allergy, renal function, cultures and recent antimicrobial exposure.
Cholestyramine for obstructive pruritusUse a current BNF oral regimen in selected stable patients, separated by several hours from other medicines to limit binding interactions.