Retrospective Study
Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Feb 16, 2015; 7(2): 128-134
Published online Feb 16, 2015. doi: 10.4253/wjge.v7.i2.128
Endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis: From guidelines to clinical practice
Joana Magalhães, Bruno Rosa, José Cotter
Joana Magalhães, Bruno Rosa, José Cotter, Gastroenterology Department, Centro Hospitalar do Alto Ave, 4835-044 Guimarães, Portugal
José Cotter, Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, 4710-057 Braga, Guimarães, Portugal
José Cotter, ICVS/3B’s, PT Government Associate Laboratory, 4710-057 Braga, Guimarães, Portugal
Author contributions: Magalhães J participated in the design of the study, performed data analysis and literature research and drafted the manuscript; Rosa B performed literature research and critically revised the manuscript; Cotter J critically revised the manuscript and approved the final version to be submitted; all the authors read and approved the final manuscript.
Ethics approval: This study was approved by the institutional review board of Centro Hospitalar do Alto Ave, Guimarães, Portugal.
Informed consent: All patients provided written consent to undergo endoscopic retrograde cholangiopancreatography and were informed of the risks and potential benefits of the procedure.
Conflict-of-interest: The authors declare that there is no conflict of interests regarding the publication of this paper.
Data sharing: Technical appendix, statistical code, and dataset available from the corresponding author at The consent of the participants was not obtained but the presented data are anonymized and risk of identification is low.
Open-Access: 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:
Correspondence to: Joana Magalhães, MD, Gastroenterology Department, Centro Hospitalar do Alto Ave, Rua dos Cutileiros, Creixomil, 4835-044 Guimarães, Portugal.
Telephone: +351-253-540330 Fax: +351-253-421308
Received: September 17, 2014
Peer-review started: September 20, 2014
First decision: October 14, 2014
Revised: December 14, 2014
Accepted: December 29, 2014
Article in press: December 31, 2014
Published online: February 16, 2015

AIM: To study the practical applicability of the American Society for Gastrointestinal Endoscopy guidelines in suspected cases of choledocholithiasis.

METHODS: This was a retrospective single center study, covering a 4-year period, from January 2010 to December 2013. All patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) for suspected choledocholithiasis were included. Based on the presence or absence of predictors of choledocholithiasis (clinical ascending cholangitis, common bile duct (CBD) stones on ultrasonography (US), total bilirubin > 4 mg/dL, dilated CBD on US, total bilirubin 1.8-4 mg/dL, abnormal liver function test, age > 55 years and gallstone pancreatitis), patients were stratified in low, intermediate or high risk for choledocholithiasis. For each predictor and risk group we used the χ2 to evaluate the statistical associations with the presence of choledocolithiasis at ERCP. Statistical analysis was performed using SPSS version 21.0. A P value of less than 0.05 was considered statistically significant.

RESULTS: A total of 268 ERCPs were performed for suspected choledocholithiasis. Except for gallstone pancreatitis (P = 0.063), all other predictors of choledocholitiasis (clinical ascending cholangitis, P = 0.001; CBD stones on US, P≤ 0.001; total bilirubin > 4 mg/dL, P = 0.035; total bilirubin 1.8-4 mg/dL, P = 0.001; dilated CBD on US, P≤ 0.001; abnormal liver function test, P = 0.012; age > 55 years, P = 0.002) showed a statistically significant association with the presence of choledocholithiasis at ERCP. Approximately four fifths of patients in the high risk group (79.8%, 154/193 patients) had confirmed choledocholithiasis on ERCP, vs 34.2% (25/73 patients) and 0 (0/2 patients) in the intermediate and low risk groups, respectively. The definition of “high risk group” had a sensitivity of 86%, positive predictive value 79.8% and specificity 56.2% for the presence of choledocholithiasis at ERCP.

CONCLUSION: The guidelines should be considered to optimize patients’ selection for ERCP. For high risk patients specificity is still low, meaning that some patients perform ERCP unnecessarily.

Keywords: Choledocholithiasis, Endoscopic retrograde cholangiopancreatography, Cholangitis, Common bile duct stones, Dilated common bile duct

Core tip: The American Society for Gastrointestinal Endoscopy (ASGE) proposes a stratification of patients according to the risk for choledocholithiasis, influencing subsequent management. Our study shown that the risk stratification, according to ASGE guidelines, may improve risk estimation of choledocholithiasis and should be considered to optimize patients’ selection for endoscopic retrograde cholangiopancreatography (ERCP). However, even in the “high risk group” the specificity was low. Thus, at this point, it seems advisable that also “high risk” patients undergo further testing before being submitted to ERCP, similarly to those patients with “intermediate risk”, while for patients with “low-risk” of choledocholithiasis a watchful waiting strategy seems adequate.