01Approach to the Critical Patient/attcp52

Immediate priorities

›Biliary sepsis and shock recognition

›Reynolds pentad present (Charcot triad + hypotension + altered mental status)

›Suppurative cholangitis — emergent biliary drainage required

›Mortality approaches 10% at 7 days without source control

›Charcot triad present (fever, RUQ pain, jaundice)

›Ascending cholangitis — urgent GI and surgery consult

›Initiate IV antibiotics within 1 hour of recognition

›Hemodynamic instability

›SBP < 90 mmHg

›MAP < 65 mmHg

›Tachycardia with fever and leukocytosis

›Airway and resuscitation priorities

›Altered mental status

›Airway protection assessment

›Glasgow Coma Scale trend

›IV access and fluid resuscitation

›Two large-bore IVs or central access if unstable

›Crystalloid bolus 30 mL/kg for septic shock

›NPO status — all patients pending biliary imaging or intervention

›Time-critical interventions

›Blood cultures x2 before antibiotics in suspected cholangitis

›Empiric antibiotics immediately after cultures

›ERCP within 24 hours for moderate-severe cholangitis

›Tokyo Guidelines Grade II-III cholangitis threshold

›ERCP within 12 hours for Grade III (severe) cholangitis

Monitoring and targets

›Resuscitation targets

02History/hx88

Presenting symptoms

›Pain characteristics

›RUQ or epigastric location

›Sudden onset, steady, intense

›Radiation to right scapula or back

›Duration and pattern

›Persistence > 6 hours distinguishes from biliary colic

›Biliary colic typically resolves < 5 hours

›Postprandial trigger

›Fatty meal association

›Recurrent or progressive episodes

›Associated symptoms

›Jaundice and cholestatic features

›Scleral icterus onset timing

›Dark (tea-colored) urine

›Pale or acholic stools

›Pruritus

›Systemic infection features

›Fever and chills

›Rigors (cholangitis indicator)

›Nausea and vomiting

›Important negatives

›Absence of fever argues against cholangitis

›Absence of back-radiating pain argues against pancreatitis

Alarm features

›High-risk presentations

›Charcot triad

›Fever + jaundice + RUQ pain

›Ascending cholangitis until proven otherwise

›Reynolds pentad

›Charcot triad + hypotension + altered mental status

›Suppurative biliary sepsis — emergent drainage

›Acute epigastric pain with elevated lipase

›Gallstone pancreatitis

›CBD stone as causative agent

›Total bilirubin > 342 micromol/L with CBD dilation

›High-risk ASGE criterion

›Proceed directly to ERCP

Risk factors

›Demographic and metabolic risk

›Female sex

›Two-fold higher prevalence than male sex

›Age > 55 years

›Increasing prevalence with age

›Obesity

›Increased biliary cholesterol saturation

›Multiparity

›Progesterone-mediated gallbladder stasis

›Medical conditions

›Type 2 diabetes mellitus

›Impaired gallbladder motility

›Nonalcoholic fatty liver disease

›Metabolic syndrome association

›Hemolytic anemias

›Pigment stone formation

›Sickle cell disease, hereditary spherocytosis

›Rapid weight loss

›Bariatric surgery

›Very low calorie diet

›Prior biliary interventions

›Prior ERCP or sphincterotomy

›Increased risk of recurrent CBD stones

›Risk of resistant organisms

›Prior cholecystectomy

›CBD dilation threshold shifts to > 8 mm (vs > 6 mm with gallbladder in situ)

›Medications and ethnicity

›Estrogen and oral contraceptive use

›Increased biliary cholesterol secretion

›Octreotide, fibrates, ceftriaxone

›All increase gallstone lithogenicity

›Native American and Hispanic ethnicity

›Genetically higher prevalence

Past medical history

›Prior biliary history

›Known gallstone disease or cholecystitis

›Number and prior episodes

›Prior imaging documentation

›Prior cholecystectomy

›Date and approach

›Post-cholecystectomy CBD anatomy considerations

›Prior ERCP or sphincterotomy

›Altered CBD dynamics

›Relevant comorbidities

›Chronic liver disease or cirrhosis

›Coagulopathy assessment

›Portal hypertension implications for ERCP

›Inflammatory bowel disease

›Primary sclerosing cholangitis association

›Hemolytic disorders

›Sickle cell, spherocytosis

›Bariatric or gastrointestinal surgery

›Altered anatomy affecting ERCP access

03Physical Exam/exam55

Vital signs and general

›Hemodynamic stability assessment

›Temperature

›Fever > 38 C suggests cholangitis

›Rigors indicate bacteremia

›Blood pressure

›SBP < 90 mmHg — septic shock threshold

›MAP < 65 mmHg — resuscitation target

›Heart rate

›Tachycardia with fever as sepsis indicator

›Respiratory rate

›Tachypnea as sepsis severity marker

›General appearance

›Mental status

›Confusion or altered consciousness — Reynolds pentad component

›Agitation from hypoperfusion

›Jaundice

›Scleral icterus visible before cutaneous jaundice

›Depth correlates loosely with bilirubin level

Abdominal exam

›RUQ assessment

›Tenderness

›Moderate-severe RUQ tenderness

›Epigastric tenderness with pancreatitis

›Murphy sign

›Positive — inspiratory arrest on deep RUQ palpation

›LR+ 11.5 to 21.3 for acute cholecystitis

›Less specific for choledocholithiasis alone

04Differential Diagnosis/ddx53

Life-threatening diagnoses

›Ascending cholangitis

›ICD-10 K83.0

›Charcot triad or Reynolds pentad

›Requires urgent biliary drainage

›Gallstone pancreatitis

›ICD-10 K85.10

›Epigastric pain radiating to back

›Lipase > 3x upper limit of normal

›Biliary sepsis

›Sepsis criteria from biliary source

›Mortality 10% at 7 days in severe cholangitis

›Hepatic abscess

›ICD-10 K75.0

›Complication of untreated cholangitis

Biliary tract mimics

›Acute cholecystitis

›ICD-10 K81.0

›Positive Murphy sign (LR+ 11.5 to 21.3)

›Sonographic wall thickening and pericholecystic fluid

›CBD typically not dilated

›Primary sclerosing cholangitis

›ICD-10 K83.01

›Beaded appearance of bile ducts on MRCP

›Associated with inflammatory bowel disease

›Mirizzi syndrome

›Extrinsic CBD compression by impacted cystic duct stone

›Identified on MRCP or EUS

05Laboratory Tests/lt55

Initial diagnostic panel

›Liver function tests — cholestatic pattern

›Total and direct bilirubin

›Elevated in obstruction

›Total bilirubin > 342 micromol/L with CBD dilation = high ASGE risk

›Total bilirubin > 342 micromol/L at 48 hours has 94% specificity for persistent CBD stones

›Alkaline phosphatase

›Markedly elevated in biliary obstruction

›More sensitive than transaminases for CBD stones

›GGT

›Elevated with biliary obstruction

›Sensitive but not specific

›ALT and AST

›May be markedly elevated acutely then trend down

›Rising transaminases at 24 to 48 hours — PPV 31%, NPV 92% for persistent CBD stones

›Pancreatic enzyme

›Lipase

›> 3x upper limit of normal supports pancreatitis

›Gallstone pancreatitis in CBD stone context

›Amylase less sensitive, not required if lipase ordered

Infection and hematologic labs

›Infection markers

›Complete blood count with differential

›Leukocytosis supports cholangitis

›Leukopenia as severe sepsis marker

›Blood cultures x2

›Mandatory before antibiotics when cholangitis suspected

›Common organisms: E. coli, Klebsiella, Enterococcus

06Diagnostic Tests/dt110

Scoring Systems

›ASGE Risk Stratification Algorithm 2019

›High risk — proceed directly to ERCP

›CBD stone visualized on imaging

›Total bilirubin > 342 micromol/L with CBD dilation

›Ascending cholangitis confirmed

›Intermediate risk — EUS, MRCP, or intraoperative cholangiography

›Abnormal liver function tests

›Age > 55 years

›Dilated CBD on imaging

›Low risk — cholecystectomy without further biliary workup

›No LFT abnormalities

›No CBD dilation

›Age < 55 years

›Only 30 to 40% of intermediate-risk patients have stones confirmed at ERCP

›Tokyo Guidelines 2018 cholangitis severity grading

›Grade I (mild)

›No organ dysfunction

›Responds to supportive care

›Grade II (moderate)

›Leukocytosis > 12 or < 4 x 10^9/L

›High fever > 39 C

›Age >= 75 years

›Bilirubin > 85 micromol/L

›Albumin < 0.7x lower limit of normal

›ERCP within 24 to 48 hours

›Grade III (severe)

›Cardiovascular dysfunction (vasopressor required)

›Neurological dysfunction (altered consciousness)

›Respiratory dysfunction (PaO2/FiO2 < 300 mmHg)

›Renal dysfunction (creatinine > 177 micromol/L)

›Hepatic dysfunction (INR > 1.5)

›Hematologic dysfunction (platelet < 100 x 10^9/L)

›ERCP within 12 hours after initial stabilization

MRI

›MRCP (magnetic resonance cholangiopancreatography)

›Diagnostic performance

›Sensitivity 84 to 92% for CBD stones

›Specificity 92 to 97% for CBD stones

›Superior to CT for identifying biliary stones

›Indications

›Intermediate-risk patients without cholangitis

›Non-invasive alternative to diagnostic ERCP

›Stricture and malignancy characterization

›Biliary anatomy before surgery

›Advantages

›No radiation

›No contrast nephrotoxicity

›Identifies stones, strictures, and malignancy

›Limitations

›Availability and time constraints in ED

›Cannot perform therapeutic intervention

›Small stones < 5 mm may be missed

›Contraindications

›Incompatible metallic implants

›Hemodynamic instability

CT

›CT abdomen/pelvis with contrast

›Diagnostic performance for CBD stones

›Low sensitivity 25 to 75% for CBD stones

›Sensitivity increases for calcified stones

›Not first-line for stone detection

›Indications in choledocholithiasis workup

›Exclude other causes of acute abdomen

›Assess for complications (perforation, abscess, pancreatitis extent)

›Evaluate CBD dilation when ultrasound equivocal

›Staging of suspected malignant obstruction

›CT findings supporting choledocholithiasis

›CBD diameter > 6 mm with gallbladder in situ

›CBD diameter > 8 mm post-cholecystectomy

›Hyperdense calculi within CBD

›Pneumobilia suggests prior instrumentation or fistula

›Protocol considerations

›Renal function assessment before IV contrast

›Portal venous phase for biliary evaluation

›Limitations

›Misses majority of non-calcified cholesterol stones

›Radiation exposure

Ultrasound

›Right upper quadrant ultrasound

›Role as first-line imaging

›Identifies gallstones (sensitivity 95%, specificity > 95%)

›CBD dilation > 6 mm with gallbladder in situ

›CBD dilation > 8 mm post-cholecystectomy

›Direct stone visualization in CBD — LR+ 8.1, LR- 0.3

›Limited sensitivity for distal CBD stones (shadowing from duodenal gas)

›Supporting signs on ultrasound

›Gallbladder wall thickening (> 3 mm)

›Pericholecystic fluid

›Acoustic shadowing from stones

›CBD dilation interpretation

›Dilation alone is ASGE intermediate-risk criterion

›Normal CBD does not exclude choledocholithiasis

›EUS (endoscopic ultrasound)

›Diagnostic performance

›Sensitivity 92 to 98% for CBD stones

›Specificity 89 to 96% for CBD stones

›Superior to MRCP for small stones

›Advantages

›Same-session ERCP if stones confirmed

›Better visualization of distal CBD

›Avoids ERCP risk when stones not confirmed

›Indications

›Intermediate-risk patients

›Preferred when same-session ERCP planned

›Cochrane review finding

›EUS and MRCP have equivalent accuracy for CBD stones

›EUS may have slight advantage for small stones

›POCUS (point-of-care ultrasound)

›ED bedside role

›Rapid gallbladder and CBD assessment

›Gallstone detection and CBD dilation screen

›Guides early risk stratification decision

›Sonographic Murphy sign at bedside

07Disposition/dispo38

Admission criteria

›Mandatory admission

›Ascending cholangitis (any grade)

›Inpatient IV antibiotics and biliary drainage

›Tokyo Grade III requires ICU-level monitoring

›Gallstone pancreatitis

›NPO, IV fluids, pain management

›ERCP if cholangitis component or failure to improve

›Hemodynamic instability

›Septic shock — ICU admission

›Persistent pain or inability to tolerate oral intake

›IV analgesia and hydration required

›High-risk patients awaiting ERCP

›Confirmed or high-probability CBD stones

›Significant comorbidities

›Elderly, immunocompromised, chronic liver disease

Observation and discharge

›Observation indication

›Intermediate-risk patients with stable vitals and controlled pain

›Awaiting MRCP or EUS

›Morning ERCP planning if stone confirmed

›Discharge criteria (rare from ED)

›Incidentally found mild CBD dilation with normal LFTs

›No pain or systemic symptoms

›Reliable outpatient follow-up arranged

›Low-risk ASGE category with resolving symptoms

›Surgical referral within 1 to 2 weeks

08Treatment/t91

Initial stabilization

›Supportive care

›NPO status

›All patients with suspected choledocholithiasis

›Pending biliary imaging and intervention decision

›IV access and fluid therapy

›Isotonic crystalloid for dehydration and vomiting

›Bolus 500 mL to 1 L for hypotension or poor intake

›Antiemetics

›Ondansetron 4 mg IV q6h PRN nausea

›Metoclopramide 10 mg IV as alternative

Analgesia

›Pain management

›NSAIDs first-line

›Ketorolac 15 to 30 mg IV

›NNT approximately 3 vs placebo

›Non-inferior to opioids with fewer adverse effects

›Cochrane systematic review support

›Diclofenac 75 mg IM as alternative

›Acetaminophen adjunct

›IV acetaminophen 1 g q6h

›Equivalent analgesia in combination with low-dose opioid

›Safe in hepatic function within normal limits

›Opioids for refractory pain

›Morphine 2 to 4 mg IV q4h PRN

›May cause sphincter of Oddi spasm — use sparingly

›Hydromorphone 0.5 to 1 mg IV as alternative

›Lower sphincter of Oddi effect than morphine

Antibiotic therapy

›Antibiotic indications

›Cholangitis (any grade) — mandatory

›Sepsis from biliary source

›Not required for uncomplicated choledocholithiasis without infection

›Community-acquired mild to moderate cholangitis

›Piperacillin-tazobactam

›3.375 to 4.5 g IV q6 to q8h

›Excellent Enterobacteriaceae and Enterococcus coverage

›First-line per Tokyo Guidelines 2018

›Ceftriaxone plus metronidazole alternative

›Ceftriaxone 2 g IV q24h

›Note: ceftriaxone itself is lithogenic — use only when preferred agents unavailable

›Metronidazole 500 mg IV q8h for anaerobic coverage

›Amoxicillin-clavulanate 1.2 g IV q8h for mild disease

›Severe or healthcare-associated cholangitis

›Carbapenems

›Meropenem 1 g IV q8h

›Reserved for severe or resistant organisms

›Use when prior biliary instrumentation or healthcare exposure

›Imipenem-cilastatin 500 mg IV q6h as alternative

›Target organisms

›Enterobacteriaceae (E. coli, Klebsiella pneumoniae)

›Enterococcus spp.

›Anaerobes less common but cover in severe disease

›Duration

›3 to 5 days with adequate source control

›Extend if bacteremia or incomplete drainage

ERCP and endoscopic management

›ERCP indications and timing

›High-risk ASGE (cholangitis, bilirubin > 342 + CBD dilation, stone on imaging)

›Tokyo Grade II: ERCP within 24 to 48 hours

›Tokyo Grade III: ERCP within 12 hours after stabilization

›Class I recommendation for biliary drainage in cholangitis

›ERCP adverse event rate 6 to 15%

›Post-ERCP pancreatitis most common (4 to 10%)

›Bleeding, perforation, cholangitis

›ERCP technique options

›Sphincterotomy and stone extraction

›Standard for most CBD stones

›Balloon or basket extraction

›Large or difficult stones

›Papillary balloon dilation after sphincterotomy

›Intraductal lithotripsy (laser or electrohydraulic)

›Temporary biliary stent placement for incomplete clearance

›When ERCP fails or anatomy precludes

›Percutaneous transhepatic biliary drainage (PTBD)

›Surgical CBD exploration

Cholecystectomy

›Timing of cholecystectomy

›Same-admission cholecystectomy after CBD clearance

›Prevents recurrent biliary events

›ERCP alone without cholecystectomy: 9.2% readmission vs 2.2% with cholecystectomy

›Class I recommendation for index admission cholecystectomy

›Laparoscopic approach preferred

›Open surgery for complicated anatomy or failed laparoscopy

›Single-stage vs two-stage approaches

›Single-stage (intraoperative ERCP or laparoscopic CBD exploration)

›Shorter hospital stays

›Decreased morbidity compared with two-stage

›Two-stage (preoperative ERCP then cholecystectomy)

›Standard when early cholecystectomy not feasible

›Elderly with high surgical risk may be managed with ERCP alone

Intraoperative cholangiography

›IOC role

›Intermediate-risk patients undergoing cholecystectomy

›Identifies CBD stones not detected preoperatively

›Avoids unnecessary ERCP in ASGE intermediate-risk group

›Allows intraoperative CBD exploration if stone identified

09Special Populations/sp87

Pregnancy

›Physiologic considerations in pregnancy

›Increased gallstone risk during pregnancy

›Estrogen increases biliary cholesterol secretion

›Progesterone impairs gallbladder motility

›CBD stones occur in 0.03 to 0.3% of pregnancies

›Maternal and fetal risks

›Untreated cholangitis — sepsis risk to mother and fetus

›Premature labor risk with cholangitis

›Gallstone pancreatitis associated with preterm delivery

›Diagnostic approach in pregnancy

›Ultrasound — first-line, no radiation

›CBD dilation and gallstone assessment

›MRCP preferred over CT

›No ionizing radiation

›Gadolinium avoided — unknown fetal risk

›CT with radiation shielding if MRCP unavailable and clinical urgency

›Fetal radiation dose minimization

›Treatment in pregnancy

›Supportive care: IV fluids, NPO, analgesia

›Acetaminophen safe at standard doses

›NSAIDs after 30 weeks — risk of premature ductus arteriosus closure

›Antibiotics for cholangitis

›Ampicillin-sulbactam 3 g IV q6h — preferred in pregnancy

›Avoid: fluoroquinolones, aminoglycosides (fetal toxicity), tetracyclines

›Piperacillin-tazobactam acceptable if necessary

›ERCP in pregnancy

›Lead shielding to minimize fetal radiation

›Preferred over surgery in second trimester

›Obstetric co-management mandatory

›Laparoscopic cholecystectomy

›Second trimester safest window for surgery

›CO2 insufflation pressure < 12 mmHg to avoid fetal compromise

Geriatric

›Physiologic considerations

›Atypical presentations common

›Absence of fever does not exclude cholangitis

›Reduced pain perception — may present late

›Confusion as sole presenting symptom of cholangitis

›Higher burden of comorbidities

›Anticoagulation therapy complicates ERCP

›Renal impairment requires antibiotic dose adjustment

›Frailty increases procedural risk

›Risk stratification

›Same-admission cholecystectomy recommended even in elderly

›ERCP alone: 9.2% readmission vs 2.2% with cholecystectomy

›Individualize based on frailty and operative risk

›ERCP alone appropriate in high surgical risk elderly

›Sphincterotomy without cholecystectomy as definitive management

›Treatment modifications

›Renal function-guided antibiotic dosing

›Piperacillin-tazobactam dose reduction for eGFR < 40 mL/min

›Meropenem dose reduction for eGFR < 50 mL/min

›Volume resuscitation cautiously

›Cardiac reserve limitation

›Monitor for volume overload

›Fall and delirium prevention

›Minimize sedating medications

›Early mobility post-procedure

Pediatrics

›Epidemiology in children

›Choledocholithiasis rare in children

›Associated with hemolytic disorders (sickle cell, spherocytosis, thalassemia)

›Obesity increasing incidence in adolescents

›Biliary anatomic anomalies as predisposing factor

›Presentation differences

›Younger children — poor localization of pain

›Vomiting may predominate

›Jaundice may be only sign in neonates

›Adolescents present similarly to adults

›RUQ pain, jaundice, elevated LFTs

›Diagnostic approach

›Ultrasound first-line

›CBD diameter norms vary by age

›< 3 mm neonates, up to 5 mm in older children

›MRCP preferred over ERCP for diagnosis

›Avoids radiation and procedural risk

›ERCP in pediatrics

›Requires pediatric-sized endoscopes

›Pediatric GI specialist involvement mandatory

›Treatment

›Weight-based antibiotic dosing for cholangitis

›Ampicillin-sulbactam 200 mg/kg/day IV divided q6h (max 8 g/day ampicillin)

›Piperacillin-tazobactam 300 mg/kg/day IV divided q6h (max adult dose)

›Analgesia weight-based

›IV morphine 0.05 to 0.1 mg/kg q4h PRN

›IV acetaminophen 15 mg/kg q6h (max 75 mg/kg/day)

›Laparoscopic cholecystectomy after CBD clearance

›Approach same as adults

›Pediatric surgery consultation

10Background/b80

Epidemiology

›Prevalence and incidence

›Choledocholithiasis occurs in 10 to 20% of patients with symptomatic cholelithiasis

›10 to 15 million Americans with gallstones annually

›Approximately 1 to 2 million new cases of symptomatic gallstones per year in North America

›Leading cause of acute pancreatitis in Western countries

›Gallstones account for 35 to 40% of acute pancreatitis cases

›Complications

›Ascending cholangitis: 2 to 9% of gallstone hospital admissions

›Gallstone pancreatitis: 33 to 50% of CBD stone cases

›Mortality in severe cholangitis: up to 10% at 7 days

›Demographics

›Female predominance: 2-fold higher prevalence than males

›Increasing prevalence with age

›Age > 55 years is an ASGE intermediate-risk criterion

›Ethnic variation

›Native American and Hispanic populations: highest prevalence

›Asian populations: higher proportion of pigment stones

Pathophysiology

›Stone types and formation

›Cholesterol stones (majority in Western countries)

›Supersaturation of bile with cholesterol

›Impaired gallbladder motility promotes crystal nucleation

›Obesity, estrogen, rapid weight loss increase lithogenicity

›Pigment stones

›Black pigment: hemolytic anemia, cirrhosis

›Calcium bilirubinate precipitation

›Brown pigment: biliary infection and stasis

›Bacterial beta-glucuronidase deconjugates bilirubin

›Common in Asian populations

›Mixed stones

›Mixture of cholesterol and calcium salts

›CBD stone migration and obstruction

›Primary CBD stones form de novo in bile duct

›Usually pigment stones

›Associated with biliary stasis and infection

›Secondary CBD stones migrate from gallbladder

›Most common mechanism in Western patients

›Cystic duct passage possible with small stones

›Obstruction consequences

›Biliary hypertension proximal to obstruction

›Hepatocyte damage from bile salt accumulation

›CBD dilation as pressure relief mechanism

›Cholangitis pathogenesis

›Biliary obstruction with bacterial colonization

›Normal bile sterile; bacteria ascend from duodenum

›E. coli, Klebsiella, Enterococcus most common

›Increased CBD pressure promotes bacteremia

›Suppurative cholangitis

›Pus under pressure in CBD

›Rapid systemic dissemination

›Endotoxin-mediated organ dysfunction

Therapeutic Considerations

›Evidence base for ERCP

›ERCP with sphincterotomy and stone extraction

›Standard definitive treatment for confirmed CBD stones

›6 to 15% overall complication rate

›Post-ERCP pancreatitis 4 to 10% — most common complication

›Timing of ERCP in cholangitis

›Early ERCP (< 24-48 hours) improves outcomes in Grade II

›Urgent ERCP (< 12 hours) for Grade III cholangitis after stabilization

›Delayed ERCP associated with increased mortality and organ failure

›ERCP vs surgery for CBD clearance

›Single-stage laparoscopic CBD exploration equivalent to two-stage ERCP-then-cholecystectomy

›Shorter hospital stays with single-stage approach

›Decreased morbidity compared to two-stage

›Intraoperative cholangiography avoids unnecessary ERCP in intermediate-risk group

›Spontaneous stone passage

›Occurs in approximately 30 to 40% of patients before ERCP

›More likely with small stones < 5 mm

›Labs may normalize with spontaneous passage

›Does not eliminate need for cholecystectomy

›Post-cholecystectomy recurrence

›ERCP alone without cholecystectomy: 9.2% recurrent biliary event readmission rate

›vs 2.2% with same-admission cholecystectomy

›Primary CBD stone recurrence after sphincterotomy

›4 to 6% annual recurrence rate

›Higher with dilated CBD, pigment stones, biliary stasis

›NSAIDs in biliary colic and choledocholithiasis

›NSAIDs superior to antispasmodics for pain relief

›Cochrane review: NNT approximately 3 vs placebo

›Non-inferior to opioids with fewer adverse effects

›Mechanism: prostaglandin inhibition reduces sphincter of Oddi pressure

11Patient Discharge Instructions/pdi32

copy discharge instructions

›Discharge instructions for Choledocholithiasis

›Diagnosis explanation

›You have been diagnosed with choledocholithiasis — gallstones in your bile duct

›Bile duct stones can cause pain, jaundice, and serious infection if not treated

›Your bile duct has been cleared or you are being monitored for further treatment

›Diet and activity

›Low-fat diet until your surgery or specialist appointment

›Avoid: fried foods, full-fat dairy, red meats, processed fats

›Small frequent meals are better tolerated

›Avoid rapid weight loss programs — they increase gallstone formation

›Regular light activity is encouraged; avoid strenuous exercise if pain persists

›Medications

›Take all prescribed medications as directed

›Complete any antibiotic course fully even if feeling better

›Pain medication: take as prescribed and only as needed

›Avoid NSAIDs if kidney function is reduced — ask your doctor

›Follow-up instructions

›Surgical follow-up within 1 to 2 weeks for cholecystectomy planning

›If ERCP was performed: follow up with gastroenterologist within 1 week

›Do not delay follow-up — ERCP alone without gallbladder removal has a 9% readmission risk

›Return to emergency department immediately for

›Fever or chills

›Worsening abdominal pain not controlled by medication

›New or worsening jaundice (yellowing of skin or eyes)

›Dark urine or pale grey stools

›Persistent vomiting preventing oral intake

›Confusion, dizziness, or feeling faint

12References/r42

Guidelines and key sources

›ASGE Guideline on the Role of Endoscopy in the Evaluation and Management of Choledocholithiasis

›Buxbaum JL, Abbas Fehmi SM, Sultan S, et al.

›Gastrointestinal Endoscopy 2019

›Source of ASGE risk stratification algorithm (low, intermediate, high risk)

›PMCID PMC8594622

›Tokyo Guidelines 2018 — Antimicrobial Therapy for Acute Cholangitis and Cholecystitis

›Gomi H, Solomkin JS, Schlossberg D, et al.

›Journal of Hepato-Biliary-Pancreatic Sciences 2018

›Severity grading (Grade I, II, III) and timing of biliary drainage

›PMID 29090866

›Cochrane Review — NSAIDs for Biliary Colic

›Fraquelli M, Casazza G, Conte D, Colli A.

›Cochrane Database of Systematic Reviews 2016

›NNT approximately 3, non-inferior to opioids

›Cochrane Review — EUS Versus MRCP for Common Bile Duct Stones

›Giljaca V, Gurusamy KS, Takwoingi Y, et al.

›Cochrane Database of Systematic Reviews 2015

›Equivalent accuracy; EUS advantage for small stones

›Management of Gallstone Pancreatitis — JAMA Surgery 2024

›McDermott J, Kao LS, Keeley JA, Nahmias J, de Virgilio C.

›JAMA Surgery 2024

›Review of evidence for timing of cholecystectomy and ERCP

›One- and Two-Stage Approaches to Common Duct Stones

›Smith SM, Kelley JK, Zambito GM, Banks-Venegoni AL.

›The American Surgeon 2025

›Single-stage approach associated with shorter stays and decreased morbidity

›Management of Choledocholithiasis in the Elderly

Evidence & Review