Choledocholithiasis and obstructive jaundice — Rapid

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.
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.

Key red flags

Ascending infection

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

Gallstone pancreatitis

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

Investigation priorities

Fractionated bilirubin and liver profileFirst step

Confirm conjugated cholestasis, identify concurrent hepatic injury and establish a trajectory before intervention.

Management branches

StableSuspected duct stone

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.
Request specialist EUS if MRCP cannot answer a clinically credible question, avoiding ERCP undertaken solely to look.
For a confirmed stone, coordinate duct clearance and laparoscopic cholecystectomy through the local surgical-endoscopy service.

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

Cholestyramine for obstructive pruritusUse 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.

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