An annotated algorithm for the evaluation of choledocholithiasis.

VOLUME 53, NO. 7, 2001 Individuals with choledocholithiasis (common bile duct stones or CDL) can present with biliary colic, nonspecific abdominal pain, obstructive jaundice, cholangitis, or acute biliary pancreatitis. Individuals may also harbor asymptomatic stones that are diagnosed serendipitously. The diagnostic studies available are imperfect, and therapies range from expectant management to endoscopic stone extraction or surgery, depending on the clinical scenario. Choledocholithiasis cannot reliably be diagnosed on the basis of the patient’s history and physical examination alone. Patients with CDL may complain of nausea, emesis, bloating or right upper quadrant/ epigastric discomfort, but these symptoms are not necessarily predictive of CDL. Elevations of serum levels of alkaline phosphatase (AP), gamma glutamyl transpeptidase (GGT), aspartate aminotransferase (AST), and alanine aminotransferase (ALT) with associated symptoms suggest CDL, especially in patients with known gallbladder stones. Almost all