Biliary boulders

Abstract

Objective To examine the outcome of endoscopic retrograde cholangiopancreatography (ERCP) in the management of common bile duct (CBD) stones. Design A retrospective review of 100 consecutive ERCPs performed for CBD stones. Results 100 ERCPs were performed on 84 patients with a median cohort age of 77. Completion in this cohort, as defined by duct clearance, was achieved in 65% of cases. Completion rates fell rapidly after two ERCPs. 33% of the cohort had small stones <10 mm, and 67% had stones >10 mm. Size, but not number of stones, affected the completion rate and frequency of complications (16%). Presence of periampullary diverticulum did not affect completion or complication rates. MR cholangiopancreatography (MRCP) had a 90% sensitivity for detecting CBD stones compared with 56% for CT. Discussion and conclusions ERCP remains a high-risk procedure with a significant complication rate when performed to deal with CBD stones. MRCP should be the second choice of investigation for CBD stones. This cohort had an unusually high number of larger stones at ERCP of 67% compared with other published UK cohorts of 8%, and this was reflected in the completion and complication rate. BACKGROUNDCommon bile duct (CBD) stones are often the reason for performing a therapeutic endoscopic retrograde cholangiopancreatography (ERCP). Techniques in ERCP have improved over the past decade and studies report that 85-95% of all CBD stones can be effectively managed by conventional ERCP methods.1 2 This includes stenting in older patients with significant comorbidities. Incomplete CBD stone extraction can leave a patient at risk of recurrent cholangitis, gallstone pancreatitis and biliary obstruction, all of which are associated with a significant mortality and comorbidity in elderly patients. A large multicentre analysis showed that