Choledocholithiasis: a comparison between the clinical presentations of multiple and solitary stones in the common bile duct.

The clinical presentations of 20 patients with four or more choledochal stones were compared with those of 68 patients who had one to three choledochal stones, investigated during the same time period. All patients underwent endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy. Patients with multiple choledochal stones usually presented with insidious onset of painless jaundice, simulating malignant bile duct obstruction, in contrast to the abrupt onset of cholangitis or pain experienced by patients with one to three stones. The latter patients had an increased number of duodenal diverticula, higher bilirubins, smaller stones, and fewer positive stones as detected by ultrasound of the bile ducts. Cholesterol crystals were more numerous in duodenal aspirates of patients with multiple choledochal stones. We conclude that multiple choledochal stones have a unique, more smoldering clinical presentation, and that ERCP is the diagnostic procedure of choice. Endoscopic sphincterotomy is an efficient, simple, and safe alternative to surgery when there is no cholecystitis.