Choledocholithiasis overview
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# Overview
Choledocholithiasis is the presence of gallstones in the common bile duct.  This condition causes jaundice and liver cell damage, and is a medical emergency, requiring the endoscopic retrograde cholangiopancreatography (ERCP) procedure or surgical treatment. A tendency for this disease can be inherited.

# Historical Perspective
There is limited information about the historical perspective of choledocholithiasis

# Classification
Choledocholithiasis can be classified as Primary or Secondary. Primary Choledocholithiasis is classified based on gallstones formed directly within the biliary and obstructing the common bile duct. Primary Choledocholithiasis is composed of brownstones and is less common compared to secondary choledocholithiasis. Primary choledocholithiasis often affect the biliary tree diffusely and have both intrahepatic and extrahepatic biliary stones. Intrahepatic stones may be complicated by recurrent pyogenic cholangitis.Secondary Choledocholithiasis is classified based on gallstones formed from the gallbladder and transported to block the common bile duct. This type of Choledocholithiasis is the most common type of Choledocholithiasis. The stone composition of secondary choledocholithiasis is similar to cholelithiasis with cholesterol stone as the most common type, and the cause is identical to the causes of gallstones.

# Pathophysiology
It is understood that the Bile is made in the liver and stored in the gallbladder. Concentrated bile from the gallbladder can lead to the formation of gallstone. The stone passes from the gallbladder to the cystic duct, then into the common bile duct (CBD), and block the CBD. Primary Choledocholithiasis is formed from stones within the bile duct that occur due to bile stasis in the CBD, forming an intraductal stone. The cause of bile duct stasis includes bile duct dilatation with increasing age. Less commonly, bile stasis can result from complications from Mirizzi Syndrome or hepatolithiasis (gallstone in the biliary duct of the liver). The obstructed flow of the bile duct leads to obstructive jaundice and possibly hepatitis. The stagnant Bile can lead to infection and inflammation of the bile duct, causing bactibilia and ascending cholangitis. If the blockage is at the common bile duct after the pancreatic duct, join the CBD, it can become inflamed, with autoactivation of pancreatic enzymes leading to gallstone pancreatitis

# Causes
While stones can frequently pass through the common bile duct into the duodenum, some stones may be too large to pass through the CBD and will cause an obstruction. Choledocholithiasis causes include primary and secondary causes. Primary causes are rare, and they are usually brown pigment stones formed in the bile duct. Recurrent pyogenic cholangitis (RCC), also known as Oriental Cholangiohepatitis hepatolithiasis, is an intrahepatic brown pigment stone exclusive to individuals who live or lived in southeast Asia. It is caused by a bacterial in the bile duct, undernutrition, and parasitic infection (e.g., Clonorchis Sinensis, Opisthorchis viverrini) leading to chronic bacterial cholangitis with hepatolithiasis|primary hepatolithiasis. Secondary causes occur in greater than 85% of people in a developed country, and about 10% presents symptomatically after Cholecystectomy. Secondary causes are caused by stones from the gallbladder, with cholesterol stones being the most common.

# Differentiating Choledocholithiasis overview from Other Diseases
Choledocholithiasis must be differentiated from other diseases that cause jaundice, right upper quadrant pain, fever, nausea and vomiting, such as Cholecystitis, Perforated peptic ulcer, Acute peptic ulcer exacerbation, Amoebic liver abscess, Acute amoebic liver colitis, Acute pancreatitis, Acute intestinal obstruction, Renal colic, Acute retrocolic appendicitis.

# Epidemiology and Demographics
The incidence and prevalence of choledocholithiasis are unknown, but Choledocholithiasis has been found in 4.6% to 18.8% of patients undergoing cholecystectomy.

# Risk Factors
Common risk factors in the development of Choledocholithiasis are the same as gallstones which include being a female, age 40 or older, obesity, pregnancy, high-fat diet, rapid weight loss, and liver disease. Risk Factors can be classified as either modifiable or non-modifiable.

# Screening
There is insufficient evidence to recommend routine screening for Choledocholithiasis.

# Natural History, Complications, and Prognosis
The choledocholithiasis symptoms typically develop as a result of stone from the gallbladder blocking the common bile duct or from stone formation within the bile duct, usually asymptomatic. According to Wenckert et al., approximately 2550% of patients with retained bile duct stones developed severe complications, mainly jaundice or pancreatitis.

# Diagnosis

## History and Symptoms
Symptoms usually do not occur unless the stone blocks the common bile duct. Symptoms that may occur include, Abdominal pain in the right upper or middle upper abdomen that may come and go, sharp, cramping, or dull, Spread to the back or below the right shoulder blade, Get worse after eating fatty or greasy foods, Occurs within minutes of a meal along with Fever, Loss of appetite and Jaundice (yellowing of skin and whites of eyes).

## Physical Examination
Patients with choledocholithiasis usually asymptomatic. Physical examination of patients with choledocholithiasis is usually non-remarkable. The physical finding is associated with the complication of the disease.

## Laboratory Findings
The laboratory data may be normal in as many as a thirds of patients with choledocholithiasis, and further evaluation of the Common bile duct is recommended by imaging studies to clarify the diagnosis.

## Imaging Findings
Ultrasound is helpful first in establishing a diagnosis of Choledocholithiasis and the most common screening tool used for choledocholithiasis. Findings on ultrasound suggestive of Choledocholithiasis include dilated bile duct, visualization of stone(s), and gallstones should increase suspicion.

# Treatment

## Medical Therapy
There is no medical therapy for choledocholithiasis; the mainstay of therapy for symptomatic choledocholithiasis is surgery and reducing risk factors. Medical therapy used to treat gallstone can be recommended to choledocholithiasis secondary to gallstone.

## Surgery
The goal of treatment is to relieve the blockage. Surgery is the mainstay of treatment for symptomatic choledocholithiasis. The procedure is Biliary endoscopic sphincterotomy, an essential procedure of endoscopic retrograde cholangiopancreatography (ERCP). The procedure involves cutting the sphincter between the common bile duct and the pancreatic duct using a flexible catheter and wire to remove the stone.

## Prevention
Effective measures for the primary prevention include diet with sufficient fat and protein, maintaining a low body weight, and avoiding prolonged fasting.