Management of choledocholithiasis in the cirrhotic patient

Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES) or endoscopic papillary balloon dilation (EPBD) is the most commonly used approach for choledocholithiasis in patients with cirrhosis. If this approach fails or the patient has altered anatomy, other options include transgastric ERCP with ES or EPBD, expandable stents, and/or lithotripsy. Although cirrhotic patients have some increased risk of bleeding, there appears to be no increased risk of post-ERCP pancreatitis in these patients, and they generally do well with ERCP with ES or EPBD. Because there is some risk associated with these procedures, if suspicion is not high, it is important to confirm the presence of choledocholithiasis with imaging studies, including magnetic resonance cholangiography. Surgery is an option if endoscopic management is unsuccessful. Surgical options include laparoscopic cholecystectomy with choledochotomy, laparoscopic common bile duct exploration, and T-tube placement.