Bile duct stones (choledocholithiasis): symptoms, tests and treatment in the UK

Bile is a digestive fluid made in the liver and stored in the gallbladder. It travels along a system of narrow tubes, the bile ducts, to reach the bowel. Gallstones normally form in the gallbladder, but the NHS notes that they can be found in the gallbladder or in the bile ducts. When a stone lodges in the main duct that leads away from the liver and gallbladder, doctors call it a common bile duct stone, or choledocholithiasis.

Some stones are formed in the gallbladder and then travel down into the duct. Others are found by chance. NICE describes asymptomatic common bile duct stones as those found incidentally on imaging done for another reason in people who have been completely symptom free for at least 12 months. Whether or not a stone causes symptoms, NICE still recommends that common bile duct stones are cleared, because a stone in this position can cause complications that a stone sitting quietly in the gallbladder usually does not.

The phrase "surgical" in the topic title refers to the fact that the standard treatment pathway combines a procedure to clear the duct with surgery to remove the gallbladder, so that more stones do not form and travel down again.

The NHS says that if a gallstone blocks a bile duct it can cause tummy pain, called biliary colic. This pain may be severe, constant, last longer than 30 minutes and up to several hours, sit in the middle of the tummy or just under the ribs on the right side, and make you feel sick or be sick.

Because the duct also drains bile from the liver, a blockage can cause jaundice. The NHS describes jaundice as a yellowing of the skin or the whites of the eyes, which may come with itchy skin and darker pee and paler poo than usual. It adds that yellowing of the skin may be less noticeable on brown or black skin, but the whites of the eyes will still look yellow. Jaundice is a sign that needs prompt medical assessment because it can point to several conditions of the liver and bile system.

A stone in the lower part of the duct can also obstruct the pancreas. The NHS identifies gallstones as the most common cause of acute pancreatitis, a serious condition that needs urgent treatment in hospital. Infection of the bile can occur as well, which is one reason a high temperature or shivering alongside upper tummy pain is taken seriously.

• Severe, steady pain in the upper middle or right upper tummy lasting more than 30 minutes.

• Nausea or vomiting with the pain.

• Yellow skin or yellow whites of the eyes, itchy skin, dark pee, pale poo.

• Fever, or feeling hot, cold or shivery.

• Pain that spreads to the back, especially with being sick.

The NHS advises asking for an urgent GP appointment or getting help from NHS 111 if you have tummy pain that lasts longer than 30 minutes. It also advises calling 999 or going to A&E if you have sudden, severe pain in your tummy, pain that spreads from your tummy to your back with being sick, a very high temperature or feeling hot, cold or shivery, or skin or whites of the eyes that look yellow.

The NHS also says not to drive yourself to A&E: ask someone to drive you or call 999 for an ambulance, and bring any medicines you take with you. If you have already been told you have gallstones and your symptoms change, treat that as new information and seek advice rather than assuming it is the same problem.

NICE recommends offering liver function tests and an ultrasound scan to people with suspected gallstone disease. The blood tests show whether the liver and bile system are being affected, and ultrasound is good at showing stones in the gallbladder and a widened bile duct. The NHS likewise lists an ultrasound scan and a blood test as the usual investigations.

Ultrasound does not always show a stone in the lower end of the duct. NICE therefore recommends considering magnetic resonance cholangiopancreatography (MRCP), a scan of the bile and pancreatic ducts, if ultrasound has not detected common bile duct stones but the bile duct is dilated or the liver function tests are abnormal. If MRCP does not allow a diagnosis, NICE says to consider endoscopic ultrasound (EUS), where a small ultrasound probe on an endoscope is used to look at the duct from inside the digestive tract.

NICE also recommends referring people for further investigation if conditions other than gallstone disease are suspected, since tummy pain and jaundice have many causes.

The NHS says that if gallstones are found in your common bile duct you may have a procedure called endoscopic retrograde cholangio-pancreatography, or ERCP. It is done using a long, thin tube with a small camera inside, called an endoscope, which is passed into your stomach through your mouth. The opening of the bile duct is widened so the stones can pass through.

NICE recommends offering both bile duct clearance and laparoscopic cholecystectomy, which is gallbladder removal by keyhole surgery, to people with symptomatic or asymptomatic common bile duct stones. It says the bile duct can be cleared either surgically at the time of the keyhole operation, or with ERCP before or at the time of the operation. The choice between these depends on the hospital's skills, the person's health and how the stones were found.

If the bile duct cannot be cleared with ERCP, NICE says biliary stenting, which means placing a small tube to keep bile draining, should be used only as a temporary measure until the stones can be removed by endoscopy or surgery.

While waiting for treatment, the NHS says you may take painkillers such as paracetamol and ibuprofen, be offered stronger painkillers for severe pain, avoid foods that trigger symptoms and be advised to eat a low-fat diet.

The NHS lists several things that make gallstones more likely: being over 40, being a woman, living with obesity, having a diet that is high in fat and low in fibre, having lost weight quickly (for example through weight loss surgery), and having a condition such as diabetes or Crohn's disease. These factors apply to gallstones in general, which are the usual source of stones that end up in the bile duct.

Having one episode of duct stones does not mean they will come back after the gallbladder has been removed and the duct cleared, but it is sensible to report any new pain, jaundice or fever to a doctor promptly.

NICE advises that people avoid food and drink that triggers their symptoms until they have their gallbladder or gallstones removed, and that after removal they should not need to keep avoiding the foods that used to trigger symptoms. If eating or drinking causes the old symptoms to return, or causes new ones, after you have recovered, NICE advises seeking further advice from your GP.

Most of the practical detail, such as how long a hospital stay lasts, depends on whether the operation is planned or done urgently. NICE recommends day-case laparoscopic cholecystectomy for planned operations unless the person's circumstances or health make an inpatient stay necessary, and early surgery, within 1 week of diagnosis, for people with acute cholecystitis.

Bile duct stones are usually managed through NHS hospital gastroenterology and surgical services, often through an emergency admission if there is jaundice, infection or pancreatitis. Planned ERCP and gallbladder removal are also available through private hospitals, usually after a GP or specialist referral and with the same clinical principles. Waiting times, costs and the exact order of procedures vary between hospitals, so the treating team can explain what applies in your situation.