Published online Apr 28, 2022. doi: 10.3748/wjg.v28.i16.1692
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
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. In 2019, the ASGE guidelines were updated.
Neither 2010 nor 2019 ASGE guidelines has been studied in AGP to determine the probability of having choledocholithiasis.
Our study aimed to determine compliance with ASGE guidelines, assess outcomes, and compare 2019 vs 2010 ASGE criteria for suspected choledocholithiasis in AGP.
We conducted a retrospective cohort study of 882 patients admitted with AP to a single tertiary care center from 2008-2018. Patients with AGP were assigned low, intermediate or high risk for choledocholithiasis 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 endoscopic retrograde cholangiopancreatography (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.
Among 79 intermediate risk patients according to the 2010 ASGE guidelines, 54 (68%) underwent MRCP first whereas 25 patients (32%) went directly to ERCP. 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. In the high risk group, 64 patients (83%) had ERCP without preceding imaging. 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). 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).
In the study cohort, we demonstrated that more than half of patients with AGP have choledocholithiasis. We also found that approximately two thirds of patients in the intermediate group and 83% of patients in the high risk group followed ASGE guidelines for management of choledocholithiasis in the setting of AGP. Importantly, one patient who had a normal ERCP in the intermediate group without preceding MRCP suffered from post ERCP pancreatitis, highlighting the risk of unnecessary procedures. We also found that while the 2010 ASGE guidelines in predicting high risk for choledocholithiasis had a specificity of 75.8%, using the 2019 ASGE guidelines led to an improved specificity of 89.4%.
Further work is needed to determine the influencing factors driving deviation from the guidelines.