Common Bile Duct Stones

  • Bernd KronenbergerEmail author


Common bile duct stones (CBDS) are the most frequentcause of benign biliary obstruction requiring endoscopic treatment. Most CBDS are white to yellowish cholesterol stones or black pigment stones. They may appear as single or multiple calculi causing varying degrees of cholestasis or even biliary pancreatitis. The size ranges from small microconcrements to large stones in the order of several centimeters. CBDS smaller than the diameter of the bile duct migrate in the bile duct, and if they do not cause biliary obstruction, they may be asymptomatic and difficult to detect. Clinically relevant problems usually occur when stones get stuck and cholestasis develops. Stone extraction is required in patients with symptomatic CBDS and especially in those patients with biliary obstruction and with complications. Several methods for stone extraction exist including endoscopic, radiologic, and surgical approaches. Endoscopic retrograde cholangiopancreatography (ERCP) is less invasive than radiologic or surgical methods and therefore usually chosen as first-line treatment for stone extraction; however, ERCP bears the risk for severe procedure-associated complications such as pancreatitis, bleeding, cholangitis, and perforation. To reduce complications, unnecessary ERCPs should be avoided, and ERCP should only be performed for therapeutic stone extraction. This chapter describes diagnostic approaches and risk-based management options for CBDS.


Cholesterol stones Pigment stones Biliary obstruction Primary stones Secondary stones ERCP Microconcrements Stone extraction techniques Lithotripsy Percutaneous transhepatic cholangio-drainage (PTCD) 


  1. 1.
    European association for the study of the liver (EASL). Electronic address: EASL Clinical Practice Guidelines on the prevention, diagnosis and treatment of gallstones. J Hepatol. 2016;65(1):146–81.
  2. 2.
    Farthing M, Roberts SE, Samuel DG, Williams JG, Thorne K, Morrison-Rees S, et al. Survey of digestive health across Europe: final report. Part 1: the burden of gastrointestinal diseases and the organisation and delivery of gastroenterology services across Europe. United Eur Gastroenterol J [Internet]. 2014 Dec 13 [cited 2018 Apr 9];2(6):539–43. Available from:
  3. 3.
    Williams E, Beckingham I, El Sayed G, Gurusamy K, Sturgess R, Webster G, et al. Updated guideline on the management of common bile duct stones (CBDS). Gut [Internet]. 2017 May [cited 2018 Apr 12];66(5):765–82. Available from:
  4. 4.
    Kuzu UB, Ödemiş B, Dişibeyaz S, Parlak E, Öztaş E, Saygılı F, et al. Management of suspected common bile duct stone: diagnostic yield of current guidelines. HPB (Oxford) [Internet]. 2017 Feb [cited 2018 Apr 22];19(2):126–32. Available from:
  5. 5.
    Collins C, Maguire D, Ireland A, Fitzgerald E, O’Sullivan GC. A prospective study of common bile duct calculi in patients undergoing laparoscopic cholecystectomy: natural history of choledocholithiasis revisited. Ann Surg [Internet]. 2004 Jan [cited 2018 Apr 22];239(1):28–33. Available from:
  6. 6.
    Choi CS, Ku YJ, Yoon DY, Yun EJ, Seo YL, Lim KJ, et al. Harmonic ultrasonography for the detection of microlithiasis in the gallbladder. Ultrasonography [Internet]. 2014 Jun 28 [cited 2018 Apr 22];33(4):275–82. Available from:
  7. 7.
    Frossard JL, Hadengue A, Amouyal G, Choury A, Marty O, Giostra E, et al. Choledocholithiasis: a prospective study of spontaneous common bile duct stone migration. Gastrointest Endosc [Internet]. 2000 Feb [cited 2018 Apr 22];51(2):175–9. Available from:
  8. 8.
    Ramchandani M, Pal P, Reddy DN. Endoscopic management of acute cholangitis as a result of common bile duct stones. Dig Endosc [Internet]. 2017 Apr [cited 2018 Apr 28];29:78–87. Available from:
  9. 9.
    Lammert F, Neubrand M, Bittner R, Feussner H, Greiner L, Hagenmüller F, et al. S3-Leitlinie der Deutschen Gesellschaft für Verdauungs- und Stoffwechselkrankheiten und der Deutschen Gesellschaft für Viszeralchirurgie zur Diagnostik und Behandlung von Gallensteinen. Z Gastroenterol [Internet]. 2007 Sep [cited 2018 Apr 22];45(9):971–1001. Available from:
  10. 10.
    Jones MW, Ferguson T. Gallbladder, Mirizzi Syndrome [Internet]. StatPearls. StatPearls Publishing; 2018 [cited 2018 Mar 25]. Available from:
  11. 11.
    Koo KP, Traverso LW. Do preoperative indicators predict the presence of common bile duct stones during laparoscopic cholecystectomy? Am J Surg [Internet]. 1996 May [cited 2018 Apr 22];171(5):495–9. Available from:
  12. 12.
    Wittenburg H. Pathogenesis of gallstones. Der Gastroenterol. 2018;13:6–14.CrossRefGoogle Scholar
  13. 13.
    Chen C-H, Lin C-L, Kao C-H. Association between inflammatory bowel disease and cholelithiasis: a nationwide population-based cohort study. Int J Environ Res Public Health [Internet]. 2018 Mar 14 [cited 2018 Mar 24];15(3):513. Available from:
  14. 14.
    Sandstad O, Osnes T, Skar V, Urdal P, Osnes M. Common bile duct stones are mainly brown and associated with duodenal diverticula. Gut [Internet]. 1994 Oct [cited 2018 Apr 21];35(10):1464–7. Available from:
  15. 15.
    Mabrut J-Y, Kianmanesh R, Nuzzo G, Castaing D, Boudjema K, Létoublon C, et al. Surgical management of congenital intrahepatic bile duct dilatation, Caroliʼs disease and syndrome. Ann Surg [Internet]. 2013 Nov [cited 2018 May 5];258(5):713–21. Available from:
  16. 16.
    Doi Y, Takii Y, Ito H, Jingu N, To K, Kimura S, et al. Usefulness of endoscopic managements in patients with ceftriaxone-induced pseudolithiasis causing biliary obstruction. Case Rep Med [Internet]. 2017 [cited 2018 Mar 30];2017:1–5. Available from:
  17. 17.
    Caddy GR, Kirby J, Kirk SJ, Allen MJ, Moorehead RJ, Tham TC. Natural history of asymptomatic bile duct stones at time of cholecystectomy. Ulster Med J [Internet]. 2005 Sep [cited 2018 Apr 22];74(2):108–12. Available from:
  18. 18.
    Saito H, Kakuma T, Kadono Y, Urata A, Kamikawa K, Imamura H, et al. Increased risk and severity of ERCP-related complications associated with asymptomatic common bile duct stones. Endosc Int Open [Internet]. 2017 Sep 5 [cited 2018 Mar 31];5(9):E809–17. Available from:
  19. 19.
    Rosseland AR, Glomsaker TB. Asymptomatic common bile duct stones. Eur J Gastroenterol Hepatol [Internet]. 2000 Nov [cited 2018 Apr 22];12(11):1171–3. Available from:
  20. 20.
    Kim SB, Kim KH, Kim TN. Comparison of outcomes and complications of endoscopic common bile duct stone removal between asymptomatic and symptomatic patients. Dig Dis Sci [Internet]. 2016 Apr 20 [cited 2018 May 6];61(4):1172–7. Available from:
  21. 21.
    Möller M, Gustafsson U, Rasmussen F, Persson G, Thorell A. 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 [Internet]. 2014 Oct 1 [cited 2018 May 6];149(10):1008–13. Available from:
  22. 22.
    Yoo ES, Yoo BM, Kim JH, Hwang JC, Yang MJ, Lee KM, et al. Evaluation of risk factors for recurrent primary common bile duct stone in patients with cholecystectomy. Scand J Gastroenterol [Internet]. 2018 Feb 19 [cited 2018 Mar 25];1–5. Available from:
  23. 23.
    Nzenza TC, Al-Habbal Y, Guerra GR, Manolas S, Yong T, McQuillan T. Recurrent common bile duct stones as a late complication of endoscopic sphincterotomy. BMC Gastroenterol [Internet]. 2018 Dec 15 [cited 2018 Mar 24];18(1):39. Available from:
  24. 24.
    Gouveia C, Loureiro R, Ferreira R, Oliveira Ferreira A, Santos AA, Santos MPC, et al. Performance of the choledocholithiasis diagnostic score in patients with acute cholecystitis. GE - Port J Gastroenterol [Internet]. 2018 Jan [cited 2018 Mar 25];25(1):24–9. Available from:
  25. 25.
    Yang M-H, Chen T-H, Wang S-E, Tsai Y-F, Su C-H, Wu C-W, et al. Biochemical predictors for absence of common bile duct stones in patients undergoing laparoscopic cholecystectomy. Surg Endosc. 2008;22(7):1620–4.CrossRefGoogle Scholar
  26. 26.
    Maple JT, Ben-Menachem T, Anderson MA, Appalaneni V, Banerjee S, Cash BD, et al. The role of endoscopy in the evaluation of suspected choledocholithiasis. Gastrointest Endosc [Internet]. 2010 Jan [cited 2018 Apr 12];71(1):1–9. Available from:
  27. 27.
    Aljebreen A. Role of endoscopic ultrasound in common bile duct stones. Saudi J Gastroenterol [Internet]. 2007 [cited 2018 Apr 28];13(1):11. Available from:
  28. 28.
    Giljaca V, Gurusamy KS, Takwoingi Y, Higgie D, Poropat G, Štimac D, et al. Endoscopic ultrasound versus magnetic resonance cholangiopancreatography for common bile duct stones [Internet]. Vol. 2015, Cochrane Database Syst Rev. 2015 [cited 2018 Apr 28]. p. CD011549. Available from:
  29. 29.
    Vaynshtein J, Sabbag G, Pinsk I, Rahmani I, Reshef A. Predictors for choledocholitiasis in patients undergoing endoscopic ultrasound. Scand J Gastroenterol [Internet]. 2018 Mar 4 [cited 2018 Mar 25];53(3):335–9. Available from:
  30. 30.
    Lee S-L, Kim H-K, Choi H-H, Jeon B-S, Kim T-H, Choi J-M, et al. Diagnostic value of magnetic resonance cholangiopancreatography to detect bile duct stones in acute biliary pancreatitis. Pancreatology [Internet]. 2018 Jan [cited 2018 Mar 29];18(1):22–8. Available from:
  31. 31.
    Bove A, Di Renzo RM, Palone G, Testa DC, Malerba V, Bongarzoni G. Single-stage procedure for the treatment of cholecysto-choledocolithiasis: a surgical procedures review. Ther Clin Risk Manag [Internet]. 2018 Feb [cited 2018 Mar 25];Volume 14:305–12. Available from:
  32. 32.
    Akashi T, Tachibana Y, Matsuo S, Gibo J. Worsening of acute cholangitis caused by a bile duct stone after hospitalization: a case series. Gastroenterol Res [Internet]. 2018 Feb [cited 2018 Mar 24];11(1):58–61. Available from:
  33. 33.
    Yang J, Li W, Si X, Zhang J, Cao Y. Efficacy and safety of therapeutic ERCP in the elderly. Surg Laparosc Endosc Percutan Tech [Internet]. 2018 Jan 18 [cited 2018 Mar 29];1. Available from:
  34. 34.
    Yıldırım AE, Öztürk ZA, Konduk BT, Balkan A, Edizer B, Gulsen MT, et al. The safety and efficacy of ERCP in octogenarians: a comparison of two geriatric age cohorts. Acta Gastroenterol Belg [Internet]. [cited 2018 Mar 24];80(2):263–70. Available from:
  35. 35.
    Iida T, Kaneto H, Wagatsuma K, Sasaki H, Naganawa Y, Nakagaki S, et al. Efficacy and safety of endoscopic procedures for common bile duct stones in patients aged 85 years or older: a retrospective study. Pagnini C, editor. PLoS One [Internet]. 2018 Jan 3 [cited 2018 Mar 29];13(1):e0190665. Available from:
  36. 36.
    Al-Mansour MR, Fung EC, Jones EL, Zayan NE, Wetzel TD, Martin del Campo SE, et al. Surgeon-performed endoscopic retrograde cholangiopancreatography. Outcomes of 2392 procedures at two tertiary care centers. Surg Endosc [Internet]. 2017 Dec 22 [cited 2018 Mar 29]. Available from:
  37. 37.
    Barthet M, Lesavre N, Desjeux A, Gasmi M, Berthezene P, Berdah S, et al. Complications of endoscopic sphincterotomy: results from a Single Tertiary Referral Center. Endoscopy [Internet]. 2002 Dec [cited 2018 Mar 31];34(12):991–7. Available from:
  38. 38.
    Vezakis A, Polydorou A, Kontis E, Pantiora E, Papanikolaou IS, Fragulidis G. Safety and efficacy of extending a previous endoscopic sphincterotomy for the treatment of retained or recurrent common bile duct stones. Ann Gastroenterol [Internet]. 2017 [cited 2018 Mar 29];31(1):109–14. Available from:
  39. 39.
    Zheng M, Liu X, Li N, Li W-Z. Emergency endoscopic needle-knife precut papillotomy in acute severe cholangitis resulting from impacted common bile duct stones at duodenal papilla. Dig Liver Dis [Internet]. 2018 Mar [cited 2018 Mar 29];50(3):267–70. Available from:
  40. 40.
    Furuya CK, Sakai P, Marinho FRT, Otoch JP, Cheng S, Prudencio LL, et al. Papillary fistulotomy vs conventional cannulation for endoscopic biliary access: a prospective randomized trial. World J Gastroenterol [Internet]. 2018 Apr 28 [cited 2018 May 5];24(16):1803–11. Available from:
  41. 41.
    Tsai T-J, Lin C-K, Lai K-H, Chan H-H, Wang E-M, Tsai W-L, et al. Does preserved sphincter of Oddi function prevent common bile duct stones recurrence in patients after endoscopic papillary balloon dilation? J Chinese Med Assoc [Internet]. 2018 Apr [cited 2018 Mar 25];81(4):311–5. Available from:
  42. 42.
    Disario JA, Freeman ML, Bjorkman DJ, Macmathuna P, Petersen BT, Jaffe PE, et al. Endoscopic balloon dilation compared with sphincterotomy for extraction of bile duct stones. Gastroenterology [Internet]. 2004 Nov [cited 2018 Mar 25];127(5):1291–9. Available from:
  43. 43.
    Yang X-M, Hu B. Endoscopic sphincterotomy plus large-balloon dilation vs endoscopic sphincterotomy for choledocholithiasis: A meta-analysis. World J Gastroenterol [Internet]. 2013 Dec 28 [cited 2018 Apr 13];19(48):9453. Available from:
  44. 44.
    Maruta A, Iwashita T, Uemura S, Yoshida K, Iwata K, Mukai T, et al. Comparison of late adverse events after endoscopic sphincterotomy versus endoscopic papillary large balloon dilation for common bile duct stones: a propensity score-based cohort analysis. Dig Endosc [Internet]. 2018 Feb 27 [cited 2018 Mar 29]. Available from:
  45. 45.
    Yasuda I. Novel retrieval basket for small bile duct stones. Dig Endosc [Internet]. 2015 Sep [cited 2018 Apr 12];27(6):712–712. Available from:
  46. 46.
    Ahn D-W, Lee SH, Paik WH, Song BJ, Park JM, Kim J, et al. Effects of saline irrigation of the bile duct to reduce the rate of residual common bile duct stones: a multicenter, prospective, randomized study. Am J Gastroenterol [Internet]. 2018 Apr 27 [cited 2018 Apr 7];113(4):548–55. Available from:
  47. 47.
    García-Cano J, Reyes-Guevara AK, Martínez-Pérez T, Valiente-González L, Martínez-Fernández R, Viñuelas-Chicano M, et al. Fully covered self-expanding metal stents in the management of difficult common bile duct stones. Rev Esp Enferm Dig [Internet]. 2013 Jan [cited 2018 Apr 8];105(1):7–12. Available from:
  48. 48.
    Saito H, Kadono Y, Kamikawa K, Urata A, Imamura H, Matsushita I, et al. The incidence of complications in single-stage endoscopic stone removal for patients with common bile duct stones: a propensity score analysis. Intern Med [Internet]. 2018 Feb 15 [cited 2018 Mar 31];57(4):469–77. Available from:
  49. 49.
    Cerefice M, Sauer B, Javaid M, Smith LA, Gosain S, Argo CK, et al. Complex biliary stones: treatment with removable self-expandable metal stents: a new approach (with videos). Gastrointest Endosc [Internet]. 2011 Sep [cited 2018 Apr 8];74(3):520–6. Available from:
  50. 50.
    Kamiyama R, Ogura T, Okuda A, Miyano A, Nishioka N, Imanishi M, et al. Electrohydraulic lithotripsy for difficult bile duct stones under endoscopic retrograde cholangiopancreatography and peroral transluminal cholangioscopy guidance. Gut Liver [Internet]. 2018 Feb 8 [cited 2018 Mar 25]. Available from:
  51. 51.
    Brown NG, Camilo J, Nordstrom E, Yen RD, Fukami N, Brauer BC, et al. Advanced ERCP techniques for the extraction of complex biliary stones: a single referral center’s 12-year experience. Scand J Gastroenterol [Internet]. 2018 Apr 12 [cited 2018 May 6];1–6. Available from:
  52. 52.
    Turowski F, Hügle U, Dormann A, Bechtler M, Jakobs R, Gottschalk U, et al. Diagnostic and therapeutic single-operator cholangiopancreatoscopy with SpyGlassDSTM: results of a multicenter retrospective cohort study. Surg Endosc [Internet]. 2018 Mar 12 [cited 2018 Mar 24]. Available from:
  53. 53.
    Brewer Gutierrez OI, Bekkali NLH, Raijman I, Sturgess R, Sejpal D V., Aridi HD, et al. Efficacy and safety of digital single-operator cholangioscopy for difficult biliary stones. Clin Gastroenterol Hepatol [Internet]. 2017 Oct 24 [cited 2018 Mar 31]. Available from:
  54. 54.
    Buxbaum J, Sahakian A, Ko C, Jayaram P, Lane C, Yu CY, et al. Randomized trial of cholangioscopy-guided laser lithotripsy versus conventional therapy for large bile duct stones (with videos). Gastrointest Endosc [Internet]. 2018 Apr [cited 2018 Apr 12];87(4):1050–60. Available from:
  55. 55.
    Deprez P, Garces Duran R, Moreels T, Furneri G, Demma F, Verbeke L, et al. The economic impact of using single-operator cholangioscopy for the treatment of difficult bile duct stones and diagnosis of indeterminate bile duct strictures. Endoscopy [Internet]. 2018 Feb 24 [cited 2018 Mar 31];50(2):109–18. Available from:
  56. 56.
    Ghersi S, Fuccio L, Bassi M, Fabbri C, Cennamo V. Current status of peroral cholangioscopy in biliary tract diseases. World J Gastrointest Endosc [Internet]. 2015 May 16 [cited 2018 Apr 29];7(5):510. Available from:
  57. 57.
    Okugawa T, Tsuyuguchi T, K C S, Ando T, Ishihara T, Yamaguchi T, et al. Peroral cholangioscopic treatment of hepatolithiasis: Long-term results. Gastrointest Endosc [Internet]. 2002 Sep [cited 2018 Apr 29];56(3):366–71. Available from:
  58. 58.
    Ellis RD, Jenkins AP, Thompson RP, Ede RJ. Clearance of refractory bile duct stones with extracorporeal shockwave lithotripsy. Gut [Internet]. 2000 Nov [cited 2018 Apr 29];47(5):728–31. Available from:
  59. 59.
    Clouse ME, Stokes KR, Lee RG, Falchuk KR. Bile duct stones: percutaneous transhepatic removal. Radiology [Internet]. 1986 Aug [cited 2018 May 6];160(2):525–9. Available from:
  60. 60.
    Nagashima I, Takada T, Shiratori M, Inaba T, Okinaga K. Percutaneous transhepatic papillary balloon dilation as a therapeutic option for choledocholithiasis. J Hepatobiliary Pancreat Surg [Internet]. 2004 Aug [cited 2018 May 6];11(4):252–4. Available from:
  61. 61.
    Peng Y-C, Chow W-K. Alternative percutaneous approach for endoscopic inaccessible common bile duct stones. Hepatogastroenterology [Internet]. [cited 2018 May 6];58(107–108):705–8. Available from:
  62. 62.
    Weigand K, Kandulski A, Zuber-Jerger I, Mueller M, Goessmann H. Cholangioscopy-guided electrohydraulic lithotripsy of large bile duct stones through a percutaneous access device. Endoscopy [Internet]. 2018 Feb 16 [cited 2018 May 6];50(5):E111–2. Available from:
  63. 63.
    Liu Z, Zhang L, Liu Y, Gu Y, Sun T. Efficiency and safety of one-step procedure combined laparoscopic cholecystectomy and eretrograde cholangiopancreatography for treatment of cholecysto-choledocholithiasis: a randomized controlled trial. Am Surg [Internet]. 2017 Nov 1 [cited 2018 Mar 31];83(11):1263–7. Available from:
  64. 64.
    Pan L, Chen M, Ji L, Zheng L, Yan P, Fang J, et al. The safety and efficacy of laparoscopic common bile duct exploration combined with cholecystectomy for the management of cholecysto-choledocholithiasis. Ann Surg [Internet]. 2018 Mar 12 [cited 2018 Mar 24];1. Available from:

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Department of Internal Medicine, Gastroenterology, Hepatology, DiabetologyHerz-Jesu-HospitalFuldaGermany

Personalised recommendations