Intrahepatic bile duct stones

Disease Description (Causes and Symptoms)

• Definition: A common bile duct stone (CBD stone) is a stone that forms in the common bile duct, where the intrahepatic bile ducts and cystic duct converge and connect to the duodenum. It can block the flow of bile and cause jaundice, cholangitis, pancreatitis, and other conditions.
• Causes
  • Secondary bile duct stones: Occur when gallstones formed in the gallbladder pass through the cystic duct and move into the common bile duct.
  • Primary bile duct stones: Occur when stones form within the bile duct from the outset and may be associated with bile stasis or bacterial/parasitic infection.
• Pathophysiology: Partial or complete obstruction of the common bile duct by a stone can cause bile stasis and bacterial proliferation, leading to acute cholangitis. Depending on the degree of obstruction, it may cause jaundice, increased bile duct pressure, and pancreatitis due to reflux into the pancreatic duct.
• Main symptoms: Asymptomatic (found incidentally) → upper abdominal (right upper abdominal) pain, nausea and vomiting, jaundice, fever and chills (in cases of cholangitis), and, in some cases, symptoms of gallstone pancreatitis.

Treatment Methods

• Basic principles: Because there is a risk of complications (acute suppurative cholangitis, sepsis, liver abscess, pancreatitis, etc.), appropriate stone removal treatment is often recommended even when there are no symptoms.
• Endoscopic treatment
  • ERCP (endoscopic retrograde cholangiopancreatography) + sphincterotomy, followed by stone removal using a balloon or retrieval basket — the primary standard treatment (diagnosis and treatment can be performed simultaneously).
  • Endoscopic ultrasound (EUS) or MRCP is used for noninvasive diagnosis.
• Surgical/non-surgical alternatives
  • Laparoscopic cholecystectomy (LC): When gallbladder stones are also present, cholecystectomy is performed after removing the bile duct stones with ERCP to prevent recurrence.
  • Percutaneous endoscopic approach: May be used in patients for whom ERCP access is impossible due to gastrectomy or other reasons.
  • Open surgery or biliary-enteric anastomosis may be considered in complex cases or when treatment fails.
• Medication/conservative treatment
  • When acute cholangitis is present, antibiotics are administered (depending on severity and culture results), along with supportive care such as fluids, painkillers, and nutritional management.
  • Medication that dissolves the stones themselves (bile acids) has a limited role in common bile duct stones.
• Lifestyle management and precautions
  • If symptoms are present or liver function abnormalities persist, treatment is needed without delay.
  • Patients taking anticoagulants need to discuss with their treating physician whether and when to stop them before the procedure.
  • If the gallbladder remains and gallbladder stones are the cause, cholecystectomy is recommended.

Checklist Before an Outpatient Visit (Including Examples of Preparations and Questions)

• Items to bring (recommended)
  • A list of recently used medications (including anticoagulants and antiplatelet agents)
  • Records of previous surgeries (cholecystectomy, upper abdominal surgery, gastrectomy, etc.)
  • Copies of recent blood test results (bilirubin, ALP, AST/ALT, etc.) and imaging studies (ultrasound, CT, MRCP)
  • The onset and changes in symptoms (fever, jaundice, frequency and intensity of pain), and recent temperature records
• Information to tell the doctor during the outpatient visit
  • Current symptoms (location and intensity of pain, fever and chills, itching, etc.)
  • Ask whether any medications need to be stopped (for example, anticoagulants)
  • Whether you have previously undergone ERCP, EUS, or laparoscopic surgery, and the results
• Precautions regarding test preparation
  • If an ERCP is scheduled, follow fasting instructions and adjust anticoagulants and antiplatelet agents as needed.
  • Fever or jaundice may require emergency treatment, so prompt medical evaluation is recommended.

Examples of General Questions to Ask the Doctor

• "Is ERCP absolutely necessary for my current condition? What are the risks?"
• "How high is the risk of complications after ERCP (pancreatitis, bleeding, infection)?"
• "If I have gallstones, when should I undergo cholecystectomy?"
• "Are there any foods or activities I should avoid in daily life?"

Examples of Disease-Specific Questions

• "I am taking anticoagulants. How should they be adjusted before and after ERCP?"
• "If the gallbladder is removed, how much can it reduce the recurrence of common bile duct stones? Why do you recommend cholecystectomy?"