Common Bile Duct Stones · ERCP vs Laparoscopic Bile Duct Exploration

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Cholangitis? + ASGE risk stratification
   Acute cholangitis? ASGE risk stratification? (High-risk markers: CBD stone on US/CT, clinical cholangitis, bilirubin >4 mg/dL + CBD >6 mm.)
   • Acute cholangitis/obstructive jaundice + sepsis → Cholangitis → emergency ERCP
   • High-risk (stone on US/CT, cholangitis, bilirubin >4 + CBD >6 mm) → High-risk → clearance (two-stage/single-stage)
   • Intermediate-risk (abnormal LFTs/age >55/dilated CBD) → Intermediate-risk → confirm first
   • Low-risk → Low-risk → cholecystectomy ± IOC
2. [End] Cholangitis → emergency ERCP
   Acute cholangitis/obstruction + sepsis → emergency ERCP drainage (stone extraction/stent) + antimicrobials + resuscitation; cholecystectomy once stable.
3. [End] High-risk → clearance (two-stage/single-stage)
   High-risk → direct bile duct clearance: pre-/intraoperative ERCP (two-stage) or laparoscopic bile duct exploration LCBDE + cholecystectomy (single-stage, transcystic/transcholedochal); clinically equivalent, single-stage has shorter stay, choose by local resources and expertise.
4. [End] Intermediate-risk → confirm first
   Intermediate-risk → further testing (EUS or MRCP, or intraoperative cholangiography IOC) to confirm; stone confirmed → clear as high-risk; negative → cholecystectomy.
5. [End] Low-risk → cholecystectomy ± IOC
   Low-risk → laparoscopic cholecystectomy ± intraoperative cholangiography (IOC); no routine duct exploration needed.

Source guidelines & references

• Management of common bile duct stones (ASGE 2019 risk stratification; SAGES biliary guideline)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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