Role of Endoscopy in the Evaluation and Management of Choledocholithiasis

Publication Date: June 1, 2019
Last Updated: March 14, 2022


In patients with intermediate risk of choledocholithiasis we suggest either EUS or MRCP given high specificity; consider factors including patient preference, local expertise, and availability. (Conditional, Low)

In patients with gallstone pancreatitis without cholangitis or biliary obstruction/choledocholithiasis we recommend against urgent (<48 hours) ERCP. (Strong, Low)

In patients with large choledocholithiasis we suggest performing large balloon dilation after sphincterotomy rather than endoscopic sphincterotomy alone. (Conditional, Moderate)

For patients with large and difficult choledocholithiasis we suggest intraductal therapy or conventional therapy with papillary dilation. This may be impacted by local expertise, cost, patient and physician preferences. (Conditional, Very low)

Same-admission cholecystectomy is recommended for patients with mild gallstone pancreatitis. (, )

In order to minimize the risk of diagnostic ERCP, we suggest the following HIGH-RISK criteria to directly prompt ERCP for suspected choledocholithiasis: (1) CBD stone on ultrasound or cross-sectional imaging or (2) Total bilirubin >4 mg/dL AND dilated common bile duct on imaging (>6 mm with gallbladder in situ)* or (3) Ascending cholangitis. In patients with INTERMEDIATE-RISK criteria of abnormal liver tests or age >55 years or dilated CBD on ultrasound, we suggest EUS, MRCP, laparoscopic intraoperative cholangiography (IOC), or laparoscopic intraoperative ultrasound for further evaluation.y For patients with symptomatic cholelithiasis without any of these risk factors, we suggest cholecystecomy without IOC. (, )

We suggest that pre- or postoperative ERCP or laparoscopic treatment be performed for patients at high risk of choledocholithiasis or positive IOC depending on local surgical and endoscopic expertise. (, )

For patients with Mirizzi syndrome, peroral cholangioscopic therapy may be an alternative to surgical management depending on local expertise; however, gallbladder resection is needed regardless of strategy. For hepatolithiasis we suggest a multidisciplinary approach including endoscopy, interventional radiology, and surgery. (, )

Plastic and covered metal stents may facilitate removal of difficult choledocholithiasis but require planned exchange or removal. (, )

Recommendation Grading




Role of Endoscopy in the Evaluation and Management of Choledocholithiasis

Authoring Organization

Publication Month/Year

June 1, 2019

Last Updated Month/Year

June 13, 2023

Document Type


External Publication Status


Country of Publication


Inclusion Criteria

Female, Male, Adolescent, Adult, Child, Older adult

Health Care Settings

Emergency care, Hospital, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant


Diagnosis, Management, Treatment

Diseases/Conditions (MeSH)

D042883 - Choledocholithiasis, D001652 - Bile Ducts


endoscopy, choledocholithiasis, bile duct stones, sphincterotomy


Number of Source Documents
Literature Search Start Date
September 21, 2017
Literature Search End Date
November 16, 2017