Snapshot A 49-year-old obese Hispanic female presents to a community physician early in the morning with progressively worsening yet constant RUQ pain that worsened after eating a fatty meal. She presents today because the pain now seems to wrap around her epigastrium "like a belt." Laboratory results reveal leukocytosis with left shift and mild transaminitis. She obtains a RUQ ultrasound scan, which reveals the presence of extrahepatic duct dilatation. The physician refers her to the local gastroenterologist for an endoscopic retrograde cholangiopancreatography (ERCP) for common bile duct stone extraction. Her recovery is uneventful. She is scheduled for a cholecystectomy in 2 weeks. Introduction Presence of gallstones within the common bile duct Presentation 50% are asymptomatic Frequently with pre-existing biliary colic Tenderness in RUQ or epigastrium Acholic stool, dark urine, fluctuating jaundice Primary versus secondary stones primary: formed in bile duct, indicating bile duct pathology secondary: formed in gallbladder (majority of cases) Evaluation Labs usually normal possible leukocytosis early elevation of AST and ALT late elevation of ALP, GGT, conjugated bilirubin (suggests obstruction) amylase/lipase to assess for gallstone pancreatitis Imaging first line: transabdominal ultrasound intra/extra-hepatic ductal dilatation if present, must consider choledochal cyst ERCP (diagnostic and therapeutic) MRCP (diagnostic not therapeutic) Predictors of choledocholithiasis (American Society of Gastrointestinal Endoscopy) very strong U/S evidence of CBD stone (ductal dilatation) clinical ascending cholangitis elevated bilirubin (> 4 mg/dL) strong CBD dilated > 6 mm on U/S bilirubin 1.8 - 4 mg/dL moderate abnormal LFTs age > 55 years clinical gallstone pancreatitis Treatment if no evidence of cholangitis, ERCP for CBD stone extraction follow up with elective cholecystectomy if cholangitis present, treat this first