Biliary stone disease (cholelithiasis) is a common etiology of abdominal pain in the United States. Although choledocholithiasis (bile duct stones) represents a diagnostic possibility in almost any setting of biliary stone disease, certain risk factors should be elicited from the patient to develop a diagnostic perspective.

In the setting of jaundice, elevated serum bilirubin, and pancreatitis, a dilated common bile duct is should lead to a careful search for distal obstructing stones. Up to 15% of patients having cholelithiasis, also have choledocholithiasis. The size of the extrahepatic bile duct is the most sensitive means of determining obstruction (whether seen or unseen). Furthermore, although there are some special cases, CBD should measure less than or equal to 4mm + 1mm per decade after 40.


Ultrasound remains up to 95% sensitive in the detection of cholelithiasis. However, detection of common duct stones remains at approximately 80%. Certain maneuvers (drinking water, using compression with the US probe) and certain positions (RPO, R lateral decubitus) can assist with detection. Sometimes the overlying bowel & gas can obscure imaging by ultrasound. A level and cause of the obstruction needs to be obtained to guide the need for further tests, diagnostic and therapeutic procedures. Options include MR cholangiogram, CT, and endoscopic procedures.

About 90% of biliary obstructions and subsequent biliary ductal dilatation occur distally and are caused by 3 entities:
1) pancreatic carcinoma
2) choledocholithiasis
3) chronic pancreatitis with stricture formation

If the diagnosis is uncertain then further diagnostic studies should be undertaken to better delineate these etiologies.

Complications of choledocholithiasis include strictures, complicatiosn of operative procedures, and cholangitis.

Although the clinical setting will dictate—especially in the presence of infection—stones < 6mm typically can pass on their own. Until that time every effort is made to make the patient most comfortable. For larger stones surgical management remains the mainstay of therapy.