Choledocholithiasis

Dr. Baig-Lewis presented a very interesting outpatient case of a older gentleman with a history of PUD and GERD who had multiple recurrent outpatient presentations for epigastric pain --> RUQ pain, nausea, vomiting, and subsequently developed significant weight loss and jaundice. He was ultimately found to have choledocholithiasis!

Learning Points:

Choledocholithiasis often presents with RUQ or epigastric pain, nausea, and vomiting. It is usually secondary to passage of stones from the gallbladder into the CBD, though there are some circumstances were stones form in the CBD as well. Labs often show a cholestatic pattern with elevated total bilirubin and alk phos relative to AST and ALT. Complications of choledocholithiasis include pancreatitis and cholangitis.

One major focus of the report was regarding which imaging modality to order for this gentleman. We debated the utility of ordering a RUQ ultrasound vs CT abdomen as our initial study of choice for this gentleman, given the concern for possible malignancy. Dr. Baig-Lewis reviewed an article, entitled ["Diagnostic Accuracy of MRCP as Compared to Ultrasound/CT in Patients with Obstructive Jaundice"][1] published in 2014 in the Journal of Clinical and Diagnostic Research. This prospective study showed that MRCP had higher accuracy for both benign and malignant diseases compared to US and CT. However, when comparing the sensivity, specificity, and diagnostic accuracy of ultrasound compared to CT imaging, ultrasound had better diagnostic accuracy for choledocholithiasis and CT imaging had better diagnostic accuracy for malignant conditions.

Additionally this case highlighted many important aspects including the possibility of anchoring bias (which occurred during his first two outpatient visits where the focus was anchored on his known history of PUD and GERD). It highlighted the importance of expanding the differential and utilizing history and physical exam when a patient presents multiple times with the same symptoms despite treatment of the presumed condition.

Given our two leading diagnoses were choledocholithiasis and malignancy, we discussed the "painful" vs "painless" manifestation of this gentleman's jaundice. Dr. Shatzel subsequently shared two articles (Prospective Study of Clinical and Biochemical Features of Symptomatic Choledocholithiasis and Signs and Symptoms of Pancreatic Cancer: A Population-Based Case-Control Study in the San Francisco Bay Area). The tables below from the articles showed that pain was often prevalent (75%) in choledocholithiasis, but more rare 33% in pancreatitic cancer.

A few other resources for timing of cholecystectomy:

Acute Cholecystitis: Early Versus Delayed Cholecystectomy, A Multicenter Randomized Trial https://journals.lww.com/annalsofsurgery/Abstract/2013/09000/Acute_Cholecystitis__Early_Versus_Delayed.2.aspx

Single-stage laparoscopic common bile duct exploration and cholecystectomy versus two-stage endoscopic stone extraction followed by laparoscopic cholecystectomy for patients with concomitant gallbladder stones and common bile duct stones: a randomized controlled trial

https://link.springer.com/article/10.1007/s00464-013-3237-4