An assessment of existing risk stratification guidelines for the evaluation of patients with suspected choledocholithiasis

Abstract

Existing guidelines performed suboptimally for predicting choledocholithiasis in our patient population, similar to other validation studies. These findings further underscore the importance of developing alternate risk stratification tools for choledocholithiasis, aiming to minimize unnecessary diagnostic ERCP.

Current clinical algorithms for predicting common bile duct stones have only moderate accuracy

“…Several risk‐stratification algorithms using predictors such as liver function tests (LFT), presence of cholangitis or pancreatitis, or findings on ultrasound (US) have been proposed . Recent studies have attempted to validate the commonly used guidelines of the American Society for Gastrointestinal Endoscopy (ASGE) for the prediction of CBD stones, but their conclusions have been somewhat conflicting . Furthermore, prediction algorithms other than that developed by ASGE have not been externally validated.…”

Once upon a Time a Guideline Was Used for the Evaluation of Suspected Choledocholithiasis: A Fairy Tale or a Nightmare

“…Of the 92 patients with an intermediate risk for choledocholithiasis, 45 (48.9%) had stones on ERCP (accuracy 39.95%). Another study from the USA retrospectively analyzed 71 patients which met ASGE high-risk probability criteria for CBD stones [16] . Of these, only 39 (54%) were found to have a stone on ERCP.…”

“…I remember that patients at high risk were defined as having a probability of choledocholithiasis >50%. Published series reported that patients with high-risk criteria for CBD stones had a documented stone/sludge in a range between 40 and 79.8% (average 60.1%) of the ERCPs [2,3,5,[14][15][16] . The majority of the published series concluded that the ASGE criteria demonstrated a probability of >50% of the patients having CBD stones.…”

“…The majority of the published series concluded that the ASGE criteria demonstrated a probability of >50% of the patients having CBD stones. However, authors should also consider that the ASGE guidelines performed suboptimally, and the application of the current guidelines would lead to unnecessary diagnostic ERCPs in more than one-third of the patients, which is not acceptable [2,3,5,[14][15][16] .…”

“…He et al [5] suggest that a revised algorithm with more stringent criteria that includes choledocholithiasis on abdominal US and/or bilirubin levels >4 mg/dL plus CBD dilation on abdominal US may improve patient selection and reduce the risk of diagnostic ERCP. However, in the clinical scenario, most of the authors [3,5,[14][15][16] , including myself, advocate the use of alternative diagnostic strategies for all patients with high and intermediate probability of choledocholithiasis, namely MRCP or EUS before ERCP. The ASGE guidelines should be used carefully because they are not a fairy tale for sure, and a lifethreatening complication of a diagnostic ERCP is always a nightmare.…”