Q1: What are the treatment options for this patient?

These are summarised in fig 1. Endoscopic extraction of common bile duct stones after spincterotomy and mechanical lithotripsy has a success rate of up to 95% and is considered the treatment of choice.^1,2 The reason for failure in this case was the large size of the bile duct calculus. Other reasons include bile duct strictures, unusual anatomy, and calculi beyond reach of the wire basket.^1–3

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Figure 1

Treatment options for common bile duct stones (CBD, common bile duct; ERCP, endoscopic retrograde cholangiopancreatography; ESWL, extracorporeal shockwave lithotripsy).

Traditionally such patients have been referred for surgical exploration of the common bile duct but this procedure is not without risk, particularly in elderly patients or those with major medical comorbidities.⁴

Extracorporeal shock wave lithotripsy (ESWL) was investigated initially for treatment of gallbladder stones, but a high stone recurrence rate has limited its use in this condition. ⁵ In recent years high energy ESWL has been used with more promising results in high risk patients with common bile duct stones.

In this case, given the patient’s age and comorbidities it was decided that this was the treatment of choice. Biliary drainage was achieved during initial ERCP using a pigtail stent.

The patient then underwent one session of high energy ESWL, during which the calculus was targeted by ultrasonography.^1,2 Studies have shown that between 20% and 50% of patients will require more than one treatment session.^3,6,7 The success rate of this procedure, with complete clearance of the common bile duct is between 80% and 90%.^1–3,6

The main complication is cholangitis (1%–8%) and this is reduced by use of prophylactic antibiotics.^1,6 Procedure related mortality has not been reported.

Q2: What does the post-treatment ercp film (fig1 in questions; see p 178) show?

At repeat ERCP the pigtail stent was removed and the cholangiogram shows no evidence of calculi with satisfactory drainage from the common bile duct.

Spontaneous passage of calculi occurs in up to 10% of patients, with 80% requiring removal of stone fragments during repeat ERCP.¹ Although recurrence of bile duct calculi is estimated at 14% after one year, most of these are amenable to endoscopic treatment.²

ESWL is an effective non-invasive treatment modality that can be performed safely on an outpatient basis, without use of general anaesthesia. For this reason it is a useful treatment option in patients with difficult common bile duct calculi who are considered to be poor candidates for surgery.

Final diagnosis

Extracorporeal shock wave lithotripsy as a treatment option for common bile duct calculi.