Original Article
Prospective Evaluation of the Clinical Features of Choledocholithiasis: Focus on Abdominal Pain
Abstract
Objectives: Although abdominal pain is a cardinal feature of choledocholithiasis, there has been little formal study of the features of pain in this condition. The objective of this study was to prospectively evaluate the clinical, laboratory, and radiological features of common bile duct stones, focusing on the characteristics of abdominal pain.Methods: All of the patients evaluated for choledocholithiasis at the time of endoscopic cholangiopancreatography during a 3.5-year period were prospectively interviewed and evaluated. Specific features of abdominal pain were recorded, including pertinent radiographic and laboratory data and endoscopic cholangiopancreatography findings.
Results: During the 42-month study period, 61 patients (mean age 55.3 years; 42.6% men) were identified; 31 patients (50.8%) had undergone cholecystectomy. Of the 52 patients who reported pain, abdominal pain was most commonly described as constant (100%), located in the epigastrium alone (65%) or both the epigastrium and the right upper quadrant (25%), occurring at night (44.3%), and radiating to the back (59.6%) with the number of distinct pain episodes before diagnosis ranging from 1 to 20. The median duration of pain was 3 hours and ranged from 20 minutes to 2 days. Associated symptoms of nausea (69.2%) and vomiting (30.7%) were common. No differences in pain characteristics were detected between those with or without a prior cholecystectomy. Liver tests were abnormal in all patients, with serum transaminase values being most elevated.
Conclusions: In our study, choledocholithiasis had a characteristic pattern of constant epigastric pain radiating to the back that was associated with nausea. A prior episode was common. The most common laboratory abnormality was transaminase elevation, and the most common imaging finding was common bile duct dilatation.
This content is limited to qualifying members.
Existing members, please login first
If you have an existing account please login now to access this article or view purchase options.
Purchase only this article ($25)
Create a free account, then purchase this article to download or access it online for 24 hours.
Purchase an SMJ online subscription ($75)
Create a free account, then purchase a subscription to get complete access to all articles for a full year.
Purchase a membership plan (fees vary)
Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.
References
1. Peery AF, Dellon ES, Lund J, et al. Burden of gastrointestinal disease in the United States: 2012 update. Gastroenterology 2012;143:1179-1187.
2. Everhart JE, Khare M, Hill M, et al. Prevalence and ethnic differences in gallbladder disease in the United States. Gastroenterology 1999;117:632-639.
3. Portincasa P, Moschetta A, Palasciano G. Cholesterol gallstone disease. Lancet 2006;368:230-239.
4. Ruhl CE, Everhart JE. Gallstone disease is associated with increased mortality in the United States. Gastroenterology 2011;140:508-516.
5. Stinton LM, Myers RP, Shaffer EA. Epidemiology of gallstones. Gastroenterol Clin North Am 2010;39:157-169.
6. Bonfrate L, Wang DQ, Garruti G, et al. Obesity and the risk and prognosis of gallstone disease and pancreatitis. Best Pract Res Clin Gastroenterol 2014;28:623-635.
7. Abboud PA, Malet PF, Berlin JA, et al. Predictors of common bile duct stones prior to cholecystectomy: a meta-analysis. Gastrointest Endosc 1996;44:450-455.
8. Kama NA, Atli M, Doganay M, et al. Practical recommendations for the prediction and management of common bile duct stones in patients with gallstones. Surg Endosc 2001;15:942-945.
9. National Institutes of Health. Gallstones and laparoscopic cholecystectomy. https://consensus.nih.gov/1992/1992gallstoneslaparoscopy090html.htm. Published September 1992. Accessed March 9, 2016.
10. Shiozawa S, Tsuchiya A, Kim DH, et al. Useful predictive factors of common bile duct stones prior to laparoscopic cholecystectomy for gallstones. Hepatogastroenterology 2005;52:1662-1665.
11. Tranter SE, Thompson MH. Spontaneous passage of bile duct stones: frequency of occurrence and relation to clinical presentation. Ann R Coll Surg Engl 2003;85:174-177.
12. Moller M, Gustafsson U, Rasmussen F, et al. Natural course vs interventions to clear common bile duct stones: data from the Swedish Registry for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks). JAMA Surg 2014;149:1008-1013.
13. Anciaux ML, Pelletier G, Attali P, et al. Prospective study of clinical and biochemical features of symptomatic choledocholithiasis. Dig Dis Sci 1986;31:449-453.
14. Sharara AI, Mansour NM, El-Hakam M, et al. Duration of pain is correlated with elevation in liver function tests in patients with symptomatic choledocholithiasis. Clin Gastroenterol Hepatol 2010;8:1077-1082.
15. Liu TH, Moody FG. Pathogenesis and presentation of common bile duct stones. Semin Laparosc Surg 2000;7:224-231.
16. Wilcox CM, Kim H, Trevino J, et al. Prevalence of normal liver tests in patients with choledocholithiasis undergoing endoscopic retrograde cholangiopancreatography. Digestion 2014;89:232-238.
17. Nathwani RA, Kumar SR, Reynolds TB, et al. Marked elevation in serum transaminases: an atypical presentation of choledocholithiasis. Am J Gastroenterol 2005;100:295-298.
18. Shemesh E, Czerniak A, Bar-El J, et al. Choledocholithiasis: a comparison between the clnical presentations of multiple and solitary stones in the common bile duct. Am J Gastroenterol 1989;84:1055-1059.
19. Roston AD, Jacobson IM. Evaluation of the pattern of liver tests and yield of cholangiography in symptomatic choledocholithiasis: a prospective study. Gastrointest Endosc 1997;45:394-399.
20. Zakaria S, Zaheer S, Donohue JH. Biliary stone disease. In: Kelly KA, Sarr MG, Hinder RA, eds. Mayo Clinic Gastrointestinal Surgery. Philadelphia: Saunders, 2004:225-245.
21. Hungness ES, Soper NJ. Management of common bile duct stones. In: Yeo CJ, Matthews JB, McFadden DW, et al., eds. Shackelford’s Surgery of the Alimentary Tract. 7th ed. vol. 2. Philadelphia: Elsevier, 2013:1326-1332.
22. Wang DQH, Afdhal NH. Gallstone disease. In: Feldman M, Friedman LS, Brandt LJ, eds. Gastrointestinal and Liver Disease. Philadelphia: Elsevier Saunders, 2016:1100-1133.
23. Ko CW, Lee SP. Gallstones. In: Alpers DH, Kalloo AN, et al.Yamada T, eds. Textbook of Gastroenterology. Hoboken, NJ: Wiley-Blackwell; 2009:1952-1977.
24. Caddy GR. The digestive system. In: Rakel RE, Bope ET eds. Conn’s Current Therapy. Philadelphia: Saunders Elsevier; 2008:489.
25. Schiff L, Schiff ER.Diseases of the Liver. 6th ed. Philadelphia: JB Lippincott, 1987:1289-1335.
26. French EB, Robb WA. Biliary and renal colic. Br Med J 1963;2:135-138.
27. Gunn A, Keddie N. Some clinical observations on patients with gallstones. Lancet 1972;2:239-241.
