How to manage patients with a suspicion of gallstone migration into the common bile duct ?

Symptomatic cholelithiasis associated with modified liver and pancreas function tests should raise the suspicion of a gallstone migration into the common bile duct (CBD). CBD evaluation is mainly done by endoscopic ultrasound or magnetic resonance cholangio-pancreatography. CBD stone retrieval is performed by endoscopic retrograde cholangio-pancreatography (ERCP). Patients at low-risk of CBD stone should be treated by cholecystectomy without further investigation, whereas high-risk patients should undergo CBD clearance before cholecystectomy. For intermediate-risk patients, we recommend initial cholecystectomy with intraoperative cholangiogram, followed if necessary by postoperative ERCP.