Existing guidelines aim to stratify the likelihood of choledocholithiasis in order to guide the use of ERCP versus a lower risk diagnostic study such as EUS, magnetic resonance cholangiopancreatography (MRCP), or intraoperative cholangiography.
To assess the performance of existing guidelines in predicting choledocholithiasis and to determine if trends in laboratory parameters improve diagnostic accuracy.
Retrospective cohort study.
Hospitalized patients presenting with suspected choledocholithiasis over a 6 year period.
Assessment of the American Society for Gastrointestinal Endoscopy (ASGE) guidelines, its component variables, and laboratory trends in predicting choledocholithiasis.
MAIN OUTCOME MEASUREMENTS
The presence of choledocholithiasis confirmed by EUS, MRCP, or ERCP.
One hundred seventy-nine (35.9%) of the 498 eligible patients met ASGE high-probability criteria for choledocholithiasis on initial presentation. Of those, 99 subjects (56.3%) had stone/sludge on subsequent confirmatory test. Among cases not meeting high-probability criteria on presentation, 111 (34.8%) had a stone/sludge. The overall accuracy of the guidelines in detecting choledocholithiasis was 62.1% (47.4% sensitivity, 73% specificity) based upon data available at presentation. The accuracy was unchanged when incorporating the second set of liver chemistries obtained after admission (63.2%), suggesting that laboratory trends did not improve performance.
retrospective study; inconsistent timing of second set of biochemical markers.
In our cohort of patients, existing choledocholithiasis guidelines lacked diagnostic accuracy, likely resulting in overuse of ERCP. Incorporation of laboratory trends did not improve performance. Additional research focused on risk stratification is necessary toward the goal of eliminating unnecessary diagnostic ERCP.