Original article
Clinical endoscopy
Preoperative predictors of choledocholithiasis in patients presenting with acute calculous cholecystitis

https://doi.org/10.1016/j.gie.2018.11.017Get rights and content

Background and Aims

Markedly increased liver chemistries in patients presenting with acute calculous cholecystitis (AC) often prompt an evaluation for concomitant choledocholithiasis (CDL). However, current guidelines directing the workup for CDL fail to address this unique population. The aims of this study are to define the range of presenting laboratory values and imaging findings in AC, develop a model to predict the presence of concurrent CDL, and develop a management algorithm that can be easily applied on presentation.

Methods

We conducted a retrospective review of patients presenting with AC to a large tertiary hospital over a 3.5-year period. CDL was defined as common bile duct (CBD) stone(s), sludge, or debris seen on any of the following studies: US, CT, magnetic resonance imaging/MRCP, EUS, ERCP, or intraoperative cholangiogram. A multivariable model to predict CDL was developed on 70% of the patients and validated on the remaining 30%.

Results

A total of 366 patients were identified and 65 (17.8%) had concurrent CDL. Univariable analysis was used to predict CDL and demonstrated statistically significant odds ratios for transaminases >3 times the upper limit of normal, alkaline phosphatase (AlkPhos) above normal, lipase >3 times the upper limit of normal, total bilirubin ≥1.8 mg/dL, and CBD diameter >6 mm. In the validation cohort, an optimal model containing alanine transaminase (ALT) >3 times the upper limit of normal, abnormal AlkPhos, and CBD diameter >6 mm was found to have an area under the receiver operating curve of 0.91. When 0 or 1 risk factors were present, 98.6% of patients did not have CDL. When all 3 risk factors were present, 77.8% were found to have CDL.

Conclusions

The prevalence of CDL is high among patients with AC. When a validated model is used, application of cutoffs for ALT, AlkPhos, and CBD diameter can effectively triage patients with low and high likelihood for CDL to surgery or ERCP, respectively.

Introduction

The diagnosis of acute calculous cholecystitis (AC) involves a combination of clinical, laboratory, and imaging findings.1, 2 The initial laboratory evaluation of patients with suspected cholecystitis often reveals modest increases in serum transaminases, alkaline phosphatase (AlkPhos), and total bilirubin. In situations where these indices are significantly increased, concern for concomitant choledocholithiasis (CDL) is often raised. Depending on the clinical suspicion for CDL, the preoperative evaluation traditionally involves one or more of the following investigations: EUS, MRCP, intraoperative cholangiogram (IOC), or ERCP.3, 4, 5, 6, 7, 8, 9 These tests can be expensive, invasive, associated with significant adverse events, and often delay definitive care.10, 11, 12, 13

Much of the motivation for this approach comes from American Society for Gastrointestinal Endoscopy (ASGE) guidelines directed at identifying patients who are at high risk for CDL.4 However, these guidelines are derived largely from studies of individuals without cholecystitis, and thus likely represent a distinct and separate patient population from those with concomitant AC. In addition, these guidelines have been limited by poor performance on retrospective validation studies and may result in unnecessarily high referral rates for diagnostic ERCP.14, 15 Other studies to address this question in patients with AC have had similar limitations.16, 17, 18, 19, 20, 21

It remains unclear if unique factors predict the presence of bile duct stones in this specific subset of patients and when further testing should be performed for intermediate-risk patients.20 We set out to both identify the distribution of presenting laboratory and imaging features and create a model to appropriately direct patients who would benefit from preoperative endoscopic intervention or imaging before cholecystectomy.

Section snippets

Materials and methods

We performed a retrospective review of all patients presenting between January 1, 2013, and June 30, 2016, with a preoperative clinical diagnosis of AC who underwent a cholecystectomy on the same admission to the University of Michigan Medical Center, a large tertiary academic medical center. The study was approved by the University of Michigan Institutional Review Board (study ID, HUM00115511). To identify patients, we queried our electronic medical record database for ICD-9 and ICD-10 codes

Patient population

A total of 737 patients were identified in our query of the medical records and, of these individuals, 366 patients met the inclusion criteria (Fig. 1). The most frequent reason for exclusion was cholecystectomy done for reasons other than AC (biliary colic, gallstone pancreatitis, acalculous cholecystitis, ascending cholangitis). Table 1 shows the general characteristics for the study population. The mean age of the patients was 52.0 years and 40.4% were male. Most of the surgeries (77.9%)

Discussion

The presence of significantly abnormal liver indices in patients presenting with AC poses a significant diagnostic and therapeutic dilemma. Suspicion for concurrent CDL can delay definitive cholecystectomy, sometimes inappropriately when CDL is ultimately not identified. In addition, assessment of CBD stones in the background of concomitant AC likely represents a subset of patients distinct from those addressed by current management guidelines and thus requires a tailored approach. In this

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    DISCLOSURE: All authors disclosed no financial relationships relevant to this publication.

    See CME section; p. 1044.

    Drs Govani and Prabhu contributed equally to this article.

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