Retrospective Study
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Apr 28, 2022; 28(16): 1692-1704
Published online Apr 28, 2022. doi: 10.3748/wjg.v28.i16.1692
Evaluating the accuracy of American Society for Gastrointestinal Endoscopy guidelines in patients with acute gallstone pancreatitis with choledocholithiasis
Supisara Tintara, Ishani Shah, William Yakah, Awais Ahmed, Cristina S Sorrento, Cinthana Kandasamy, Steven D Freedman, Darshan J Kothari, Sunil G Sheth
Supisara Tintara, Cristina S Sorrento, Cinthana Kandasamy, Department of Internal Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
Ishani Shah, William Yakah, Awais Ahmed, Steven D Freedman, Sunil G Sheth, Division of Gastroenterology & Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
Darshan J Kothari, Division of Gastroenterology, Duke University Medical Center, Durham, NC 27710, United States
Darshan J Kothari, Division of Gastroenterology, Durham VA Medical Center, Durham, NC 27705, United States
Author contributions: Tintara S, Shah I, Ahmed A, Freedman SD, Kothari DJ and Sheth SG contributed to the study design and coordination; Tintara S contributed to the acquisition and interpretation of data, and primarily drafting the manuscript; Shah I assisted in drafting the manuscript; Yakah W contributed to the acquisition and interpretation of data and statistical analysis; Ahmed A, Sorrento CS and Kandasamy C contributed to the acquisition of data; Freedman SD contributed to revision of manuscript for intellectual content; Kothari DJ and Sheth SG contributed to the interpretation and analysis of data, revision of manuscript for intellectual content, and study supervision; All authors have approved the final draft submitted.
Institutional review board statement: This retrospective observational cohort study was approved by Beth Israel Deaconess Medical Center institutional review board.
Informed consent statement: Informed written consent was obtained fromthe patient for publication of this report and any accompanying images.
Conflict-of-interest statement: The authors of this study have no relevant conflict of interests to declare.
Data sharing statement: Statistical code, and dataset available from the corresponding author at ssheth@bidmc.harvard.edu. This retrospective observational cohort study was approved by the Beth Israel Deaconess Medical Center institutional review board which did not require individual patient consent for retrospective chart review.
STROBE statement: This manuscript adheres to the applicable Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines for cohort studies.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Sunil G Sheth, AGAF, FACG, FASGE, MBBS, MD, Associate Professor, Division of Gastroenterology & Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA 02215, United States. ssheth@bidmc.harvard.edu
Received: December 10, 2021
Peer-review started: December 10, 2021
First decision: January 27, 2022
Revised: February 7, 2022
Accepted: March 16, 2022
Article in press: March 16, 2022
Published online: April 28, 2022
Processing time: 134 Days and 21.5 Hours
Abstract
BACKGROUND

Acute gallstone pancreatitis (AGP) is the most common cause of acute pancreatitis (AP) in the United States. Patients with AGP may also present with choledocholithiasis. In 2010, the American Society for Gastrointestinal Endoscopy (ASGE) suggested a management algorithm based on probability for choledocholithiasis, recommending additional imaging for patients at intermediate risk and endoscopic retrograde cholangiopancreatography (ERCP) for patients at high risk of choledocholithiasis. In 2019, the ASGE guidelines were updated using more specific criteria to categorize individuals at high risk for choledocholithiasis. Neither ASGE guideline has been studied in AGP to determine the probability of having choledocholithiasis.

AIM

To determine compliance with ASGE guidelines, assess outcomes, and compare 2019 vs 2010 ASGE criteria for suspected choledocholithiasis in AGP.

METHODS

We conducted a retrospective cohort study of 882 patients admitted with AP to a single tertiary care center from 2008-2018. AP was diagnosed using revised Atlanta criteria and AGP was defined as the presence of gallstones on imaging or with cholestatic pattern of liver injury in the absence of another cause. Patients with chronic pancreatitis and pancreatic malignancy were excluded as were those who went directly to cholecystectomy prior to assessment for choledocholithiasis. Patients were assigned low, intermediate or high risk based on ASGE guidelines. Our primary outcomes of interest were the proportion of patients in the intermediate risk group undergoing magnetic resonance cholangiopancreatography (MRCP) first and the proportion of patients in the high risk group undergoing ERCP directly without preceding imaging. Secondary outcomes of interest included outcome differences based on if guidelines were not adhered to. We then evaluated the diagnostic accuracy of 2019 in comparison to the 2010 ASGE criteria for patients with suspected choledocholithiasis. We performed the t test or Wilcoxon rank sum test, as appropriate, to analyze if there were outcome differences based on if guidelines were not adhered to. Kappa coefficients were calculated to measure the degree of agreement between pairs of variables.

RESULTS

In this cohort, we identified 235 patients with AGP of which 79 patients were excluded as they went directly to surgery for cholecystectomy without prior MRCP or ERCP. Of the remaining 156 patients, 79 patients were categorized as intermediate risk and 77 patients were high risk for choledocholithiasis according to the 2010 ASGE guidelines. Among 79 intermediate risk patients, 54 (68%) underwent MRCP first whereas 25 patients (32%) went directly to ERCP. For the 54 patients with intermediate risk who had MRCP first, 36 patients had no choledocholithiasis while 18 patients had evidence of choledocholithiasis prompting ERCP. Of these patients, ERCP confirmed stone disease in 11 patients. Of the 25 intermediate risk patients who directly underwent ERCP, 18 patients had stone disease. One patient with a normal ERCP developed post ERCP pancreatitis. Patients undergoing MRCP in this group had a significantly longer length of stay (5.0 vs 4.0 d, P = 0.02). In the high risk group, 64 patients (83%) had ERCP without preceding imaging, of which, 53 patients had findings consistent with choledocholithiasis, of which 13 patients (17%) underwent MRCP before ERCP, all of which showed evidence of stone disease. Furthermore, all of these patients ultimately had an ERCP, of which 8 patients had evidence of stones and 5 had normal examination.

Our cohort also demonstrated that 58% of all 156 patients with AGP had confirmed choledocholithiasis (79% of the high risk group and 37% of the intermediate group when risk was assigned based on the 2010 ASGE guidelines). When the updated 2019 ASGE guidelines were applied instead of the original 2010 guidelines, there was moderate agreement between the 2010 and 2019 guidelines (kappa = 0.46, 95%CI: 0.34-0.58). Forty-two of 77 patients were still deemed to be high risk and 35 patients were downgraded to intermediate risk. Thirty-five patients who were originally assigned high risk were reclassified as intermediate risk. For these 35 patients, 26 patients had ERCP findings consistent with choledocholithiasis and 9 patients had a normal examination. Based on the 2019 criteria, 9/35 patients who were downgraded to intermediate risk had an unnecessary ERCP with normal findings (without a preceding MRCP).

CONCLUSION

Two-thirds in intermediate risk and 83% in high risk group followed ASGE guidelines for choledocholithiasis. One intermediate-group patient with normal ERCP had post-ERCP AP, highlighting the risk of unnecessary procedures.

Keywords: American Society for Gastrointestinal Endoscopy guidelines; Choledocholithiasis; Acute gallstone pancreatitis; Endoscopic retrograde cholangiopancreatography; Magnetic resonance cholangiopancreatography

Core Tip: We demonstrated that more than half of patients with acute gallstone pancreatitis (AGP) have choledocholithiasis. We also found that approximately 2/3 of patients in the intermediate group and 83% of patients in the high risk group followed American Society for Gastrointestinal Endoscopy guidelines for management of choledocholithiasis in the setting of AGP. There was associated longer length of stay for patients undergoing magnetic resonance cholangiopancreatography (MRCP) in both groups. Importantly, one patient who had a normal endoscopic retrograde cholangiopancreatography (ERCP) in the intermediate group without preceding MRCP suffered from post ERCP pancreatitis, highlighting the risk of unnecessary procedures.