Whenever extrahepatic obstruction is likely, the biliary tree and its contents should usually be visualized by direct cholangiography. Ultrasound is often the initial imaging study used when the clinical picture is less clear. Ultrasound may suggest the need for liver biopsy to evaluate intrahepatic cholestasis and may obviate the need for more invasive tests, at least initially. Treatment Despite their varied behavior, common duct stones are a potential source of major disease and should be removed when discovered. In the setting of cholangitis, they should be removed endoscopically or surgically after initiation of antibiotic therapy.
Immediate morbidity is caused by bleeding, pancreatitis, perforation, and cholangitis.
Late complications include restenosis and reformed stones in open ducts. For older patients with choledocholithiasis and prior cholecystectomy, ERS is the procedure of choice if available. When these patients present with acute cholangitis or gallstone pancreatitis, endoscopic decompression usually results in dramatic clinical improvement, which also occurs with surgical decompression. ERS is increasingly the preferred therapy in patients with an intact gallbladder and ductal obstruction caused by a stone. When stones remain in the bile ducts despite maximal efforts to find them during biliary tract surgery, they often are discovered on postoperative cholangiography with an externally draining T tube.