Stones in the bile duct

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Stones in the bile duct can create problems by blocking the flow of bile to your intestines. Choledocholithiasis is the name of the medical condition when you have stones in the bile duct. In the last 15 years, I have personally taken care of patients who were hospitalized for stones in the bile duct. I am writing this article based on my personal experience as well as a review of relevant medical journals.

In this article, I will describe:

  1. The two types of stones in the bile duct
  2. Symptoms of stones in the bile duct with and without an infection
  3. Bile duct stones after gallbladder removal
  4. What to expect when hospitalized with stones in the bile duct

The two types of stones in the bile duct

A diagram showing several organs along with gallstones moving to the bile duct as well as a bile stone formed in the bile duct.
A diagram showing gallstones moving to the bile duct and a bile stone formed in the bile duct

There are two types of stones in the bile duct:

  1. Gallstones in the bile duct: Stones that form in the gallbladder and move to the bile duct
  2. Bile duct stones: These stones actually form in the bile duct.

Most bile duct stones are gallstones that form in the gallbladder and move to the bile duct. Gallstones inside the gallbladder may just sit there without causing any problems. Many people don’t even know they have gallstones as long as they stay inside the gallbladder. Those gallstone can be left alone. However, when they come out of the gallbladder and get stuck in the bile duct, they need to be dealt with.

In a small number of cases, the stones actually form in the bile duct. This may happen to people with or without a gallbladder. Certain diseases, such as styptic fibrosis, increase your risk for getting bile duct stones that actually form in the bile duct. Some bile duct stones after gallbladder removal are formed in the bile duct.

Symptoms of stones in the bile duct without an infection

Here are 4 possible symptoms of stones in the bile duct without an infection:

  1. Belly pain
  2. Jaundice
  3. Nausea
  4. Vomiting

Nausea and vomiting are the same as any other disease. I will go further into detail about belly pain and jaundice.

Bile duct stone pain

A diagram showing where you can feel bile duct stone pain and where it can move to.
A diagram showing where you can feel bile duct stone pain

As you can see in the picture, stones in the bile duct can get stuck and put pressure on the walls. The swollen wall gives out a pain signal. Most people initially feel bile duct pain in their belly, just below the chest. It may then move towards the right side. Pain might also be felt in other areas away from the bile duct.

A diagram showing other areas where pain from bile duct stones may be felt
A diagram showing other areas where pain from bile duct stones may be felt

The nerves that supply pain sensors to the gallbladder and the bile ducts also supply pain sensors to your liver, diaphragm, and shoulders. Pain may also be felt in those areas, even though they are not physically close to the bile duct. Back pain with bile duct stones is possible, but less frequent. Bile duct stones are usually described as an intense but dull discomfort. 

Many people get pain after a meal. A fatty meal is more likely to cause pain than a non-fatty meal. Pain does not change with body position movement. It does not get better with bowel movements or passing gas. Pain usually builds up over 30 minutes to an hour, and remains constant after that. It does not improve until the stone is out of the bile duct. Sometimes, the bile duct stone passes into the intestine on its own, and the pain goes away after several hours. In other cases, pain only goes away after the stone is removed by doctors.

Jaundice due to stones in the bile duct

A diagram showing how bile backs up after the stone blocks it, and ends up spilling back into the blood
A diagram showing how bile spills back into the blood

As you can see in this picture, a stone that is stuck in the bile duct can block the flow of bile. This blockage is the cause of jaundice.

Bile comes to the bile duct from two different organs:

  1. Liver
  2. Gallbladder

Bile is made inside the liver. From the liver, it flows directly to the bile duct and to the intestine. Some bile also flows to the gallbladder for temporary storage. The gallbladder can release bile back into the bile duct when needed.

When a stone blocks bile from coming to the bile duct, bile starts flowing backwards. The liver keeps making bile, but it has nowhere to go. Bile then backs up and spills back into the blood. As a result, the levels of bile in the blood go up, and you become jaundiced.

Bile has pigments. These pigments make the color of your skin yellowish, causing jaundice. This yellow discoloration is more clearly visible in the white areas of the eyes.

Symptoms of stones in the bile duct with an infection

When bile is blocked by stones, the bile duct can get infected. Bacteria climb up from the intestine into the bile duct, and infect the bile that is not flowing. The constant downward flow of bile from the bile duct to the intestines is like flushing the toilet. It prevents bacteria from climbing up. When the flushing stops, it gets dirty, and bacteria invade.

The infection of bile is medically known as cholangitis, and it is a potentially life-threatening condition. People who get cholangitis have all of the symptoms of stones in the bile duct that we learned previously. In addition, they have these following symptoms:

  1. Fevers and chills
  2. Dizziness and lightheadedness
  3. Low blood pressure
  4. Fast heart rate
  5. Fast and shallow breathing
  6. Confusion and disorientation

Cholangitis may lead to sepsis. Read “Low blood pressure and a fever: think about sepsis” if you would like to learn more about sepsis.

Bile duct stones after gallbladder removal

Unfortunately, gallbladder removal doesn’t always get rid of all gallstone problems. There are two types of bile duct stones that may cause problems after gallbladder removal:

  1. Residual stones: These are stones that are left behind when taking the gallbladder out. These may eventually block the bile duct and cause problems. Unfortunately, up to 10% of patients have been reported to have stones that may have been missed during the initial surgery.
  2. Recurrent stones: These are stones that form in the bile duct after gallbladder removal. This may happen many years after removal.

One study suggested that bile duct stones in people who had their gallbladder removed are more likely to get infected than stones in people who still have a gallbladder. Do not ignore symptoms of bile duct stones just because you don’t have a gallbladder.

What to expect when hospitalized with stones in the bile duct

What happens when you get hospitalized with stones in the bile duct depends on whether or not you have an infection.

Here is what you can expect when you are hospitalized for stones in the bile duct without an infection:

  1. You will be admitted to the regular medical floor
  2. You will get IV fluids and pain medications
  3. Your bile duct stone will be removed by a procedure called ERCP
  4. You might also have your gallbladder removed if you still have it.
  5. You start eating food once your pain improves, and you go home.

The full form of ERCP is endoscopic retrograde cholangiopacreatography. It means taking pictures of the bile and pancreatic ducts with the help of a scope. In reality, this procedure can do much more than just take pictures.

A diagram showing how ERCP treatment is done, with a wire, a scope with a side-view camera, and a balloon.
A diagram showing how ERCP treatment is done

As you can see, a scope with a side-viewing camera is inserted from the mouth to the upper part of the intestine, where the bile duct normally drains bile. A dye is then injected into the bile duct. This helps to see the stone and its exact position under an x-ray. After seeing the stone, a small tube with a balloon on its tip is pushed just past the stone. The balloon is then inflated, and the stone is swept backward, out of the bile duct. This is how a bile duct stone is removed by ERCP.

When you have a severe infection with sepsis along with stones in the bile duct, here is what you can expect:

  1. You will be admitted to the ICU with close monitoring
  2. You will get lots of IV fluids to help keep your blood pressure stable.
  3. You will get strong IV antibiotics
  4. You may get medications to help squeeze your heart and blood vessels if you still have low blood pressure despite IV fluids
  5. You will get an ERCP done as soon as possible
  6. You will be closely monitored in the hospital until things are stable
  7. You will eventually have your gallbladder removed if you still have it

In conclusion, most stones in the bile duct are formed in the gallbladder. A stone stuck in the bile duct needs to be removed. Bile duct stones can happen even years after your gallbladder has been removed. They are usually removed by ERCP.

https://www.racgp.org.au/afpbackissues/2004/200411/20041128mackay.pdf

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4319126/

https://jdc.jefferson.edu/cgi/viewcontent.cgi?article=1009&context=medposters

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4087957/

https://www.hindawi.com/journals/grp/2012/417821/#discussion