Comparing diagnostic accuracy of current practice guidelines in predicting choledocholithiasis: outcomes from a large healthcare system comprising both academic and community settings

Intermediate Likelihood of Choledocholithiasis: Do All Need EUS or MRCP?

“…1 These guidelines appear robust in prediction of choledocholithiasis and more specific compared with previous guidelines. [2][3][4] To consider a patient having "high-likelihood" criteria of common bile duct (CBD) stone, ASGE criteria includes: cholangitis, CBD stone on imaging or combination of total bilirubin > 4 mg/dL, and dilated CBD on ultrasound (US). High-likelihood subjects can undergo either preoperative endoscopic retrograde cholangiopancreatography (ERCP) or intraoperative cholangiogram directly.…”

“…There is also an apparent increase in number of patients in intermediate-likelihood group requiring to undergo EUS or MRCP. 1,3,4 There is need to substratify patients in "intermediate-likelihood" group, so that diagnostic tests such as EUS and MRCP are used judiciously with better cost-benefit ratio.…”

Do the 2019 ASGE choledocholithiasis guidelines reduce diagnostic ERCP?

“…5,6 Nevertheless, this was actually better than the intent of the high-risk category, which was to identify those with >50% probability of choledocholithiasis. 7 ERCP performed in the course of the current study by Chandran et al 10 occurred between 2013 and 2019. However, although only 221 patients (29.7%) met the contemporary 2010 criteria for intermediate risk of choledocholithiasis, which prompts additional imaging, 359 (48%) patients underwent MRCP, 115 (15%) IOC, and 31 (4%) EUS.…”

“…9 A final aspect of clinical guidelines, which is addressed in this issue of Gastrointestinal Endoscopy, is that they are validated in the context of patient care. 10 Chandran et al 10 investigated the performance of the new 2019 ASGE guidelines to identify patients with a high risk of biliary stones as compared with 2010 ASGE criteria. They performed an analysis of 744 randomly selected ERCPs for suspected choledocholithiasis from a large prospectively maintained dataset of ERCPs performed in 14 medical centers affiliated with the University of Texas.…”

“…If applied prospectively to the cohort, the 2019 guidelines for choledocholithiasis would have reduced the number of patients who underwent diagnostic ERCP (ie, no definite stones) from 107 (14%) according to the 2010 criteria to 48 (6%), which fulfills the intent of the 2019 revision. This was driven by the elimination of 2 criteria from the 2010 guidelinesdbilirubin 1.8 to 4 mg/dL and biliary dilatation or bilirubin >4 mg/dL alone dwhich Chandran et al 10 confirm have a specificity of <80% for definite stones. In the 2019 guidelines these were replaced by a new criterion requiring both bilirubin >4 mg/dL and biliary dilatation, which has a specificity approaching 90%, which is on par with the other 2 high-risk predictors, cholangitis and bile duct stones on imaging, which both have a specificity exceeding 90% in this cohort.…”