Differential diagnosis:
(1) retained stone in the common bile duct: This is minimized by performing intraoperative cholangiography.
(2) dysfunction of the Sphincter of Oddi
(3) functional pain
(4) disorder elsewhere (esophagitis, peptic ulceration, pancreatitis, irritable bowel syndrome)
Step 1: Does the patient have pain consistent with biliary origin?
(1) Yes: Perform ultrasonography and liver function tests while the patient is experiencing pain.
(2) No: Consider alternative diagnoses.
Step 2: Are the ultrasonography and liver function tests all normal?
(1) Yes: Provide symptomatic therapy, including analgesics and/or reassurance.
(2) No: Perform ERCP and consider Sphincter of Oddi manometry.
where:
• Ultrasonography is considered abnormal if it shows dilation of the common bile duct.
• Biliary manometry should only be done in carefully selected patients with definite evidence of a common bile duct disorder.
Step 3:
(1) Are the ERCP and/or Sphincter of Oddi manometry abnormal?
(2) Yes: Perform a sphincterotomy.
(3) No: Provide symptomatic therapy, including analgesics and/or reassurance.
where:
• Patients with a basal pressure > 30 mm Hg tend to show improvement with sphincterotomy.
• ERCP with sphincterotomy is associated with acute pancreatitis in a significant number of patients.
ERCP is usually successful in the removal of a common bile duct stone. These stones are usually small and might be retrieved or passed. However, if the stone does not pass then it might be necessary to:
(1) try lithotripsy
(2) try chemical dissolution
(3) operate in order to remove the stone if symptoms persist or recurrent infection occurs.
