Viral Hepatitis and Liver Disease Website Course

Evaluating Liver Test Abnormalities

Understanding the Pathophysiology of Liver Disease

for Health Care Providers

Choledocholithiasis (Stone in the Common Bile Duct)

Back to Acute Cholestasis


Patients generally present with acute epigastric or less commonly acute right upper quadrant (RUQ) pain. Nausea is frequent. They may also give a history of prior intermittent RUQ pain, precipitated by fatty meals. Note that presentation may be atypical in older patients and pain may be absent. Jaundice may be present, but is not a cardinal sign. Fever and rigors may be present if there is an associated ascending cholangitis. Patients with symptoms or signs suggestive of bacterial cholangitis (fever or shaking chills in addition to cholestasis) should be hospitalized.

Notably, acute cholecystitis is not associated with cholestasis unless there is external compression of the common bile duct from an inflamed gallbladder or compression of the common hepatic duct from a stone impacted in the cystic duct (Mirizzi syndrome) which occurs in less than 2% of the cases of acute cholecystitis.

Physical examination

Patients may exhibit epigastric or right upper quadrant tenderness. Scleral icterus may be present, but is not a reliable sign. In case of cholangitis, fever, tachycardia and hypotension may be present.


In addition to dilatation of the biliary tree seen in choledocholithiasis, a bile duct stone may be visualized by ultrasound. However, intestinal air frequently obscures stones in the distal common bile duct. CT scan is a more sensitive study in such cases. Nevertheless, if the suspicion is high for biliary obstruction, a confirmatory CT is not necessary and the patient should proceed directly to endoscopic retrograde cholangiopancreatogram (ERCP).