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Health condition · Clinically reviewed

Bile duct stones, MRCP, ERCP with sphincterotomy and when the gallbladder follows.

Choledocholithiasis is common, often silent and sometimes dangerous. A clear pathway from imaging to endoscopy to surgery keeps most people out of trouble.

Jump to treatment
A radiographer guides a patient onto the bed of an advanced 3 Tesla MRI scanner in a London imaging suite

Why trust this guide

  • 01

    Clinically reviewed

    Written by our editorial team and reviewed by a registered UK clinician before publication.

  • 02

    Sourced from guidance

    Checked against BSG, ESGE, NICE CG188 and Tokyo Guidelines TG18 you can see at the end.

  • 03

    Current for 2026

    Reflects modern UK hepato-pancreato-biliary practice including MRCP, ERCP with sphincterotomy and cholangioscopy.

Key facts

Bile duct stones at a glance.

The essentials in plain English: what they are, how they present and how UK hepato-pancreato-biliary teams manage them today.

  • What it is

    Choledocholithiasis is the presence of stones within the common bile duct, causing obstruction, jaundice, cholangitis or pancreatitis.

  • Two mechanisms

    Secondary stones (around 85 per cent) migrate from the gallbladder. Primary stones (around 15 per cent) form de novo in the bile duct.

  • Prevalence

    Roughly 10 to 15 per cent of people with gallbladder stones have concurrent stones in the common bile duct.

  • Stone types

    Cholesterol, brown pigment (often primary, associated with stasis and infection) and black pigment (haemolytic disease).

  • First-line imaging

    Ultrasound looks for a dilated duct and gallbladder stones. MRCP is the gold standard non-invasive test for duct stones.

  • Definitive care

    ERCP with sphincterotomy and stone extraction clears the duct in over 90 per cent of cases, followed by cholecystectomy.

Why this guide matters

A clear pathway, not a delayed diagnosis.

Duct stones can slip from silent to septic in hours. The three points below shape the rest of this page.

  • MRCP is the gold standard scan

    When ultrasound is uncertain, MRCP confirms or excludes duct stones non-invasively with sensitivity above 95 per cent.

  • ERCP is treatment, not just a test

    Sphincterotomy with basket or balloon extraction clears the duct in over 90 per cent of cases, with cholangioscopy and lithotripsy for the difficult ones.

  • Cholecystectomy follows

    Removing the gallbladder within about six weeks of ERCP clearance prevents recurrent stones, cholecystitis and repeat cholangitis.

How the diagnosis is made

From first pain to a cleared duct.

The steps a UK GP, acute physician or HPB team will normally follow, in order, so you know what to expect and why.

  1. 01

    Assessing

    History and pain pattern

    Biliary colic in the right upper quadrant or epigastrium radiating to the right shoulder, painless jaundice, or fever with rigors.

  2. 02

    Assessing

    Examination and vital signs

    Look for jaundice, right upper quadrant tenderness, and signs of sepsis or shock that suggest ascending cholangitis.

  3. 03

    Assessing

    Liver function tests

    An obstructive pattern raises ALP, GGT and bilirubin. Transaminases may spike early in acute obstruction, then settle.

  4. 04

    Confirming

    Lipase and inflammatory markers

    Lipase is checked if gallstone pancreatitis is suspected. Full blood count, CRP and blood cultures if cholangitis is on the table.

  5. 05

    Confirming

    Abdominal ultrasound

    First-line imaging: a dilated common bile duct above 6 to 8 mm and gallbladder stones support the diagnosis. The stone itself is seen in around half of scans.

  6. 06

    Confirming

    MRCP

    Magnetic resonance cholangiopancreatography is the gold standard non-invasive test for duct stones, with sensitivity above 95 per cent.

  7. 07

    Treating

    Endoscopic ultrasound or ERCP

    EUS has the highest sensitivity for small stones. ERCP is used when treatment is planned, often on the same list.

Typical timeline: from A&E presentation to cleared duct within days, followed by planned cholecystectomy.

Symptoms

What bile duct stones actually feel like.

A spectrum from silent passage to biliary colic, jaundice, gallstone pancreatitis and life-threatening cholangitis.

  • Biliary colic

    Right upper quadrant or epigastric pain radiating to the right shoulder, lasting minutes to hours, often with nausea and vomiting.

  • Obstructive jaundice

    Yellowing of skin and sclera, dark urine and pale stools, often painless and progressive as the duct blocks.

  • Ascending cholangitis

    Charcot triad of right upper quadrant pain, jaundice and fever with rigors. Reynolds pentad adds hypotension and confusion.

  • Gallstone pancreatitis

    A stone impacted at the ampulla obstructs the pancreatic duct, causing acute pancreatitis with epigastric pain and raised lipase.

  • Mirizzi syndrome

    A stone in the cystic duct compresses the common hepatic duct from outside, mimicking a duct stone or tumour.

  • Pruritus and cholestasis

    Itch, fatigue and steatorrhoea can develop with sustained obstruction, alongside deranged liver function.

  • Silent stones

    Duct stones can pass transiently and cause a self-limiting biochemical blip with no lasting symptoms.

  • Red flag: sepsis or shock

    Fever, hypotension or new confusion in a jaundiced patient is a surgical emergency needing urgent biliary drainage.

Treatment

How bile duct stones are treated in the UK.

Endoscopic clearance first, surgical exploration when appropriate, and urgent drainage for cholangitis. Follow the BSG, ESGE, NICE CG188 and Tokyo TG18 pathways.

  • ERCP with sphincterotomy

    The gold standard. A side-viewing endoscope cannulates the ampulla, cuts the sphincter and sweeps stones out with a basket or balloon. Success is above 90 per cent.

  • Cholangioscopy and lithotripsy

    Large or impacted stones (over 15 mm) are broken with mechanical, electrohydraulic or laser lithotripsy via a SpyGlass cholangioscope.

  • Laparoscopic bile duct exploration

    A single-stage alternative in specialist HPB units: choledochotomy or transcystic clearance at the time of cholecystectomy, with a T-tube if needed.

  • Laparoscopic cholecystectomy

    Removal of the gallbladder within about six weeks of duct clearance to prevent recurrent stones and cholecystitis.

  • Acute cholangitis package

    Tokyo TG18 severity grading with IV fluids, broad-spectrum antibiotics (piperacillin-tazobactam or a carbapenem) and biliary drainage within 24 to 48 hours.

  • Gallstone pancreatitis pathway

    Early ERCP if cholangitis or persistent obstruction, followed by cholecystectomy on the same admission or within two weeks.

  • Biliary stent

    A plastic or metal stent bridges obstruction when a stone cannot be cleared, or as definitive drainage in frail elderly patients.

  • Percutaneous transhepatic drainage

    When ERCP fails or is not feasible, interventional radiology can decompress the biliary tree via the liver.

What this guide is based on

The sources behind every claim on this page.

UK national guidance and specialist society standards, current at the time of last review.

Key references

Guidelines and standards we relied on.

A quiet reminder

This guide is for information, not medical advice.

Your GP or HPB team knows your history and can tell you which parts apply to you. If in doubt, get seen.

  • British Society of Gastroenterology (BSG). Guidelines on the management of common bile duct stones.

  • European Society of Gastrointestinal Endoscopy (ESGE). Endoscopic management of common bile duct stones.

  • NICE CG188. Gallstone disease: diagnosis and management.

  • Tokyo Guidelines (TG18) for the diagnosis and severity grading of acute cholangitis and cholecystitis.

Red flags

When bile duct stones need urgent attention.

Duct disease can go from painful to septic quickly. These are the situations that need same-day hospital review or 999.

  • Reynolds pentad

    Right upper quadrant pain, jaundice, fever, hypotension and confusion signal severe cholangitis and septic shock. Call 999 or go to A&E.

  • Suspected cholangitis

    Fever with rigors in a jaundiced patient needs same-day hospital assessment for IV antibiotics and urgent biliary drainage.

  • Acute pancreatitis

    Severe epigastric pain radiating to the back with vomiting warrants urgent lipase testing and admission if raised.

  • Progressive painless jaundice

    Painless and worsening jaundice is not always a stone. Malignancy of the pancreas or bile duct must be excluded.

  • Post-ERCP pain or fever

    New severe pain, fever or shortness of breath after ERCP can indicate pancreatitis, perforation or bleeding.

  • Melaena or haematemesis

    Bleeding after sphincterotomy needs emergency review, particularly in patients on anticoagulants.

  • Rising bilirubin post-op

    A rising bilirubin after cholecystectomy suggests a retained duct stone or bile duct injury and needs prompt HPB review.

  • Recurrent cholangitis

    Repeated attacks in a cleared duct raise the possibility of hepatolithiasis, stricture or biliary dysmotility.

  • Immunocompromise

    Diabetic, elderly or immunosuppressed patients can be septic with minimal signs. Have a low threshold for admission.

Living with it

A treatable problem, with a clear pathway.

Four things make the biggest difference: timely cholecystectomy, knowing warning signs, planning a short ERCP recovery, and following HPB advice for the primary-stone group.

A quiet reminder

Clearing the duct is only half the job.

Without the gallbladder coming out, most people are back with new stones within a year or two. Book the surgery, do not defer it.

  1. 01 Prevention

    Do not defer cholecystectomy

    After ERCP clearance, aim to have the gallbladder removed within six weeks to prevent recurrent stones and further attacks.

  2. 02 Symptoms

    Know your warning signs

    Fever with jaundice, worsening pain, or new confusion after a biliary event are reasons to go to A&E, not to wait.

  3. 03 Recovery

    Expect a short ERCP recovery

    Most people go home the same day or the day after. Mild sore throat and bloating are normal. Post-ERCP pancreatitis is the main risk to watch for.

  4. 04 Long term

    Follow HPB advice

    For primary stones, hepatolithiasis or biliary strictures, an HPB team may plan longer-term monitoring or endoscopic follow-up.

Frequently asked

Everything we get asked about bile duct stones.

Quick answers on MRCP, ERCP with sphincterotomy, cholangitis, gallstone pancreatitis and cholecystectomy.

  • What are bile duct stones?

    Choledocholithiasis means stones sitting in the common bile duct rather than the gallbladder. Around 85 per cent are secondary stones that have migrated from the gallbladder, and around 15 per cent are primary stones that formed in the duct itself, often related to stasis, strictures or previous cholecystectomy.

  • How are bile duct stones diagnosed?

    Blood tests show an obstructive pattern with raised ALP, GGT and bilirubin. Ultrasound is the first-line scan and may show a dilated duct and gallbladder stones. MRCP is the gold standard non-invasive test with sensitivity above 95 per cent. Endoscopic ultrasound has the highest sensitivity for small stones, and ERCP is both diagnostic and therapeutic.

  • What is ERCP and why is it used?

    Endoscopic retrograde cholangiopancreatography uses a side-viewing endoscope to cannulate the bile duct through the ampulla. A small cut is made in the sphincter (sphincterotomy) and stones are removed with a balloon or basket. Very large or impacted stones can be broken with mechanical, electrohydraulic or laser lithotripsy via a cholangioscope. Success rates are over 90 per cent.

  • Is acute cholangitis an emergency?

    Yes. The classic Charcot triad is right upper quadrant pain, jaundice and fever with rigors. If hypotension and confusion are added (Reynolds pentad), the risk of septic shock is high. Treatment follows Tokyo TG18 grading with IV antibiotics, fluid resuscitation and biliary drainage within 24 to 48 hours, or urgently within 24 hours in severe (grade III) disease.

  • Do I need my gallbladder removed after the stones are cleared?

    Almost always yes. Laparoscopic cholecystectomy is recommended within about six weeks of duct clearance because the gallbladder is a reservoir for further stones. Skipping it substantially raises the risk of recurrent stones, cholecystitis and cholangitis.

  • What if a stone cannot be removed?

    Options include mechanical, electrohydraulic or laser lithotripsy via cholangioscopy (SpyGlass), laparoscopic bile duct exploration in HPB centres, or a plastic or metal stent to bridge obstruction. In frail elderly patients a stent may be the definitive treatment. Percutaneous transhepatic drainage is used when ERCP fails.

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