GuidelineThe role of endoscopy in the evaluation of suspected choledocholithiasis
Section snippets
Initial evaluation
Choledocholithiasis is most commonly suspected in the scenarios of symptomatic cholelithiasis and acute biliary pancreatitis (ABP), with other presentations such as de novo bile duct stones in the postcholecystectomy patient occurring less often. The initial evaluation of suspected choledocholithiasis should include serum liver biochemical tests (eg, alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, and total bilirubin) and a transabdominal ultrasound (US) of the right
A risk-stratified diagnostic approach to patients with symptomatic cholelithiasis
A proposed strategy to assign risk of choledocholithiasis based on clinical predictors evident after initial diagnostic evaluation is presented in Table 2. This table summarizes the relative importance of common clinical predictors for choledocholithiasis based on the available literature; however, it is not a validated clinical decision aid. A suggested management algorithm for patients with symptomatic cholelithiasis, based on whether they are at low, intermediate, or high probability of
Recommendations
- 1.
We recommend that the initial evaluation of suspected choledocholithiasis should include serum liver biochemical tests and a transabdominal US of the right upper quadrant. ⊕⊕⊕○ These tests should be used to risk-stratify patients to guide further evaluation and management.
- 2.
We recommend that patients with symptomatic cholelithiasis who are surgical candidates and have a low probability of choledocholithiasis proceed to cholecystectomy without additional biliary evaluation (Fig. 1). ⊕⊕⊕○
- 3.
We
References (106)
- et al.
Prevalence and ethnic differences in gallbladder disease in the United States
Gastroenterology
(1999) - et al.
Burden of digestive diseases in the United States I: Overall and upper gastrointestinal diseases
Gastroenterology
(2009) - et al.
Gallstone pancreatitis: a prospective study on the incidence of cholangitis and clinical predictors of retained common bile duct stones
Am J Gastroenterol
(1998) - et al.
Prospective assessment of the utility of EUS in the evaluation of gallstone pancreatitis
Gastrointest Endosc
(1999) - et al.
Detection of choledocholithiasis by EUS in acute pancreatitis: a prospective evaluation in 100 consecutive patients
Gastrointest Endosc
(2001) - et al.
Prediction of bile duct stones and complications in gallstone pancreatitis using early laboratory trends
Am J Gastroenterol
(2001) - et al.
The elective evaluation of patients with suspected choledocholithiasis undergoing laparoscopic cholecystectomy
Gastrointest Endosc
(2004) - et al.
Is laparoscopicintraoperative cholangiogram a matter of routine?
Am J Surg
(2004) - et al.
Bile duct stones and laparoscopic cholecystectomy: a decision analysis to assess the roles of intraoperative cholangiography, EUS, and ERCP
Gastrointest Endosc
(1999) - et al.
Choledocholithiasis: a prospective study of spontaneous common bile duct stone migration
Gastrointest Endosc
(2000)
Laparoscopic endobiliary stenting: a simplified approach to the management of occult common bile duct stones
J Gastrointest Surg
EUS vs MRCP for detection of choledocholithiasis
Gastrointest Endosc
Magnetic resonance cholangiography using half-Fourier acquisition for diagnosing choledocholithiasis
Am J Gastroenterol
Choledocholithiasis: diagnostic accuracy of MR cholangiopancreatography—3 year experience
MRI
Linear EUS for bile duct stones
Gastrointest Endosc
EUS: a meta-analysis of test performance in suspected choledocholithiasis
Gastrointest Endosc
Detection of common bile duct stones: comparison between endoscopic ultrasonography, magnetic resonance cholangiography, and helical-computed-tomographic cholangiography
Eur J Radiol
Endoscopic ultrasonography for diagnosing choledocholithiasis: a prospective comparative study with ultrasonography and computed tomography
Gastrointest Endosc
Prospective controlled study of endoscopic ultrasonography and endoscopic retrograde cholangiography in patients with suspected common bile duct lithiasis
Lancet
Over-the-wire US catheter probe as an adjunct to ERCP in the detection of choledocholithiasis
Gastrointest Endosc
Major early complications from diagnostic and therapeutic ERCP: a prospective multicenter study
Gastrointest Endosc
Risk factors for post-ERCP pancreatitis: a prospective, multicenter study
Gastrointest Endosc
Complications of diagnostic and therapeutic ERCP: a prospective, multicenter study
Am J Gastroenterol
Complications of ERCP: a prospective study
Gastrointest Endosc
Wire-guided intraductal US: an adjunct to ERCP in the management of bile duct stones
Gastrointest Endosc
SpyGlass single operator peroral cholangiopancreatoscopy system for the diagnosis and therapy of bile duct disorders: a clinical feasibility study
Gastrointest Endosc
Endoscopic direct cholangioscopy by using an ultra-slim upper endoscope: a feasibility study
Gastrointest Endosc
Comparison of EUS and ERCP in the investigation with suspected biliary obstruction caused by choledocholithiasis: a randomized study
Gastrointest Endosc
Comparison of early endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography in the management of acute biliary pancreatitis: a prospective randomized study
Clin Gastroenterol Hepatol
EUS versus endoscopic retrograde cholangiography for patients with intermediate probability of bile duct stones: a prospective randomized trial
Gastrointest Endosc
EUS for suspected choledocholithiasis: do benefits outweigh costs? a prospective controlled study
Gastrointest Endosc
Sphincter of Oddi dysfunction in patients addicted to opium: an unrecognized entity
Gastrointest Endosc
Imaging patients with “post-cholecystectomy syndrome”: an algorithmic approach
Clin Radiol
Endoscopic ultrasonography versus cholangiography for the diagnosis of choledocholithiasis
Gastrointest Endosc
Controlled trial of urgent endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy versus conservative treatment for acute pancreatitis due to gallstones
Lancet
GRADE. an emerging consensus on rating quality of evidence and strength of recommendations
BMJ
Laparoscopic transcystic bile duct exploration
Am J Surg
Selective operative cholangiography: appropriate management for laparoscopic cholecystectomy
Arch Surg
Laparoscopic common bile duct exploration
Surg Endosc
Choledocholithiasis: overdiagnosed endoscopically and undertreated laparoscopically
ANZ J Surg
Biochemical predictors for absence of common bile duct stones in patients undergoing laparoscopic cholecystectomy
Surg Endosc
Useful predictors of bile duct stones in patients undergoing laparoscopic cholecystectomy
Ann Surg
Predicting the presence of choledocholithiasis in patients with symptomatic cholelithiasis
Am J Gastroenterol
Role of liver function tests in predicting common bile duct stones in patients with acute calculous cholecystitis
Br J Surg
The insensitivity of sonography in the detection of choledocholithiasis
AJR Am J Roentgenol
Grey-scale ultrasonography in cholestatic jaundice
Gut
US diagnosis of choledocholithiasis: a reappraisal
Radiology
Ultrasound detection of choledocholithiasis: prospective comparison with ERCP in the postcholecystectomy patient
Gastrointest Radiol
Ultrasonography in the diagnosis of obstructive jaundice
Ann Intern Med
A prospective comparison of the evaluation of biliary obstruction using computed tomography and ultrasonography
Radiology
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This document is a product of the Standards of Practice Committee. This document was reviewed and approved by the Governing Board of the American Society for Gastrointestinal Endoscopy. This document was reviewed and endorsed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Guidelines Committee and by the SAGES Board of Governors.