Background: Current knowledge of the characteristics of patients with choledocholithiasis is derived from subset analysis of patients with known cholecystitis or cholelithiasis. We sought to characterize the historical, clinical, and laboratory presentations of emergency department patients with choledocholithiasis, regardless of cholelithiasis, to describe the differences, if any, in these presentations versus previously described subset analysis.
Methods: We conducted a retrospective chart review at two urban academic emergency departments (EDs) with combined annual visits of 135,000. Adult (age > 18) ED patients with International Classification of Diseases, 10th revision (ICD-10) codes for gallstone pancreatitis or choledocholithiasis were identified for visits between January 1, 2014 and January 1, 2017. Patients with common bile duct stones confirmed on advanced imaging comprised the study population. We reviewed the electronic medical records of these patients for demographic information, symptoms, signs, and serum laboratory values, and imaging findings.
Results: We found 143 cases of confirmed choledocholithiasis, for an annual incidence of 5 cases per 10,000 ED visits. Forty-seven patients (33%) underwent prior cholecystectomy. Mean patient age was 51 (± 21); 90 patients (63%) were female. Nausea and vomiting was the most common historical feature, seen in 117 (82%) patients. The most common physical examination finding was right upper quadrant tenderness, noted in 87 of 143 (61%) of patients. Mean laboratory values were abnormally elevated, but with large standard deviations: alkaline phosphatase 273 IU/L (± 247), aspartate aminotransferase 264 IU/L (± 219), alanine aminotransferase 280 (± 254), and total bilirubin 3.0 (± 2.6).
Conclusion: Patients presenting to the ED with confirmed choledocholithiasis averaged 51 years of age and were 63% female, in line with prior studies. Surprisingly, a third of the patients had undergone prior cholecystectomy, some decades prior to ED presentation, calling into question the traditional teaching that common bile duct stones form in the gallbladder and then migrate into the common bile duct. No feature of history, physical examination, or laboratory values was sensitive or specific for choledocholithiasis, similar to previous studies.