Original articleClinical endoscopyPreoperative predictors of choledocholithiasis in patients presenting with acute calculous cholecystitis
Graphical abstract
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
References (33)
- et al.
The role of endoscopy in the evaluation of suspected choledocholithiasis
Gastrointest Endosc
(2010) - et al.
The elective evaluation of patients with suspected choledocholithiasis undergoing laparoscopic cholecystectomy
Gastrointest Endosc
(2004) - et al.
Has intraoperative cholangiography during laparoscopic cholecystectomy become obsolete in the era of preoperative endoscopic retrograde and magnetic resonance cholangiopancreatography?
J Am Coll Surg
(2015) - et al.
Predicting the likelihood of a persistent bile duct stone in patients with suspected choledocholithiasis: accuracy of existing guidelines and the impact of laboratory trends
Gastrointest Endosc
(2015) - et al.
When does assessment for bile duct stones need to be performed prior to cholecystectomy for calculus gallbladder disease?
Clin Gastroenterol Hepatol
(2018) - et al.
Prevalence and characteristics of clinically significant retained common bile duct stones after laparoscopic cholecystectomy for symptomatic cholelithiasis
Ann Surg Treat Res
(2016) - et al.
Prospective validation of an initial cholecystectomy strategy for patients at intermediate-risk of common bile duct stone
Gastrointest Endosc
(2017) - et al.
Technical complications are rising as common duct exploration is becoming rare
J Am Coll Surg
(2005) Clinical practice. Acute calculous cholecystitis
N Engl J Med
(2008)- et al.
Does this patient have acute cholecystitis?
JAMA
(2003)
Non-invasive assessment of choledocholithiasis in patients with gallstones and abnormal liver function
World J Gastroenterol
Clinical characteristics of acute cholecystitis with elevated liver enzymes not associated with choledocholithiasis
Eur J Gastroenterol Hepatol
Endoscopic ultrasound versus magnetic resonance cholangiopancreatography for common bile duct stones
Cochrane Database Syst Rev
The role of magnetic resonance cholangiopancreatography in the diagnosis of choledocholithiasis: do benefits outweigh the costs?
Am Surg
A systematic review and economic evaluation of magnetic resonance cholangiopancreatography compared with diagnostic endoscopic retrograde cholangiopancreatography
Health Technol Assess
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DISCLOSURE: All authors disclosed no financial relationships relevant to this publication.
See CME section; p. 1044.
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Drs Govani and Prabhu contributed equally to this article.