Tintara S, Shah I, Yakah W, Ahmed A, Sorrento CS, Kandasamy C, Freedman SD, Kothari DJ, Sheth SG. Evaluating the accuracy of American Society for Gastrointestinal Endoscopy guidelines in patients with acute gallstone pancreatitis with choledocholithiasis. World J Gastroenterol 2022; 28(16): 1692-1704 [PMID: 35581962 DOI: 10.3748/wjg.v28.i16.1692]
Corresponding Author of This Article
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
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
Retrospective Study
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (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: http://creativecommons.org/licenses/by-nc/4.0/
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
ARTICLE HIGHLIGHTS
Research 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. In 2019, the ASGE guidelines were updated.
Research motivation
Neither 2010 nor 2019 ASGE guidelines has been studied in AGP to determine the probability of having choledocholithiasis.
Research objectives
Our study aimed to determine compliance with ASGE guidelines, assess outcomes, and compare 2019 vs 2010 ASGE criteria for suspected choledocholithiasis in AGP.
Research methods
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.
Research results
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).
Research conclusions
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%.
Research perspectives
Further work is needed to determine the influencing factors driving deviation from the guidelines.
