Elsevier

Gastrointestinal Endoscopy

Volume 89, Issue 6, June 2019, Pages 1075-1105.e15
Gastrointestinal Endoscopy

Guideline
ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis

https://doi.org/10.1016/j.gie.2018.10.001Get rights and content

Each year choledocholithiasis results in biliary obstruction, cholangitis, and pancreatitis in a significant number of patients. The primary treatment, ERCP, is minimally invasive but associated with adverse events in 6% to 15%. This American Society for Gastrointestinal Endoscopy (ASGE) Standard of Practice (SOP) Guideline provides evidence-based recommendations for the endoscopic evaluation and treatment of choledocholithiasis. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework was used to rigorously review and synthesize the contemporary literature regarding the following topics: EUS versus MRCP for diagnosis, the role of early ERCP in gallstone pancreatitis, endoscopic papillary dilation after sphincterotomy versus sphincterotomy alone for large bile duct stones, and impact of ERCP-guided intraductal therapy for large and difficult choledocholithiasis. Comprehensive systematic reviews were also performed to assess the following: same-admission cholecystectomy for gallstone pancreatitis, clinical predictors of choledocholithiasis, optimal timing of ERCP vis-à-vis cholecystectomy, management of Mirizzi syndrome and hepatolithiasis, and biliary stent therapy for choledocholithiasis. Core clinical questions were derived using an iterative process by the ASGE SOP Committee. This body developed all recommendations founded on the certainty of the evidence, balance of risks and harms, consideration of stakeholder preferences, resource utilization, and cost-effectiveness.

Introduction

Bile duct stones (choledocholithiasis) most frequently result from the migration of gallstones from the gallbladder into the biliary tree. Gallstones are the consequence of cholesterol supersaturation in bile, inadequate bile salt levels or function, and diminished contractility of the biliary epithelium because of the multifactorial effects of diet, hormones, and genetic predisposition.1, 2 Prospective population data reveal that 10% of American adults will develop symptomatic gallstones over the course of a decade.2 Greater than 700,000 will undergo outpatient cholecystectomy, and despite 436,000 being managed as outpatients, the annual cost exceeds 6.6 billion dollars.2, 3 Among those with symptomatic cholelithiasis 10% to 20% have concomitant choledocholithiasis.4 An analysis using Diagnosis-Related Group (DRG); International Classification of Disease, 9th Revision (ICD-9); and Current Procedural Terminology (CPT) codes suggests that each episode of choledocholithiasis results in a cost of 9000 dollars.5 Furthermore, choledocholithiasis is the leading cause of acute pancreatitis, which results in 275,000 hospitalizations annually at a cost of 2.6 billion dollars.6

ERCP has transformed bile duct stone removal from a major operation to a minimally invasive procedure. Over the past 3 decades a number of strategies have been introduced to address even the most difficult bile duct stones, including large balloon papillary dilation and cholangioscopy-guided intraductal laser and electrohydraulic lithotripsy (EHL).7, 8 However, a significant risk (6%-15%) of major adverse events associated with ERCP-guided treatment of bile duct stones has also been recognized.9, 10 This has underscored the need to identify appropriate candidates for this procedure and to reserve biliary endoscopy for patients who have the highest probability of intraductal stones.

Section snippets

Aims/scope

The aim of this document is to provide evidence-based recommendations for the endoscopic evaluation and treatment of choledocholithiasis based on rigorous review and synthesis of the contemporary literature, using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. The GRADE framework is a system for rating the quality of evidence and strength of recommendations that is comprehensive and transparent and has been recently adopted by the American Society for

Overview

This article was prepared by a working group of the Standards of Practice (SOP) Committee of the ASGE in conjunction with a GRADE methodologist. This document includes a systematic review of available literature along with guidelines for the endoscopic diagnosis and management of choledocholithiasis. The panel members first formulated the relevant questions and agreed on patient-important outcomes for each question, which were subsequently approved by the ASGE Governing Board. The GRADE

Results

The recommendations and quality of evidence for the 4 clinical questions that were addressed using the GRADE framework are summarized in Table 4.

Future directions

A systematic assessment of the literature pertaining to the diagnosis and management of bile duct stones has identified several areas that require further study. To favor accurate comparison of different therapies a more objective, hierarchical system is needed to categorize stones, that is, large but not giant stones may be amenable to specific treatment and should be identified using a reproducible system (Table 16).69 Additionally, international consensus definitions of adverse endoscopic

Summary and conclusions

GRADE methodology was used to develop practice guidelines for the diagnosis and treatment of bile duct stones. Furthermore, they adhere to the Institute of Medicine standards for guideline creation. These Guidelines use an evidence-based approach to inform a series of practical clinical questions encountered by those caring for patients with choledocholithiasis; these include the use of MRCP versus EUS for intermediate-risk patients, the role of early ERCP for gallstone pancreatitis, and the

References (136)

  • J.T. Maple et al.

    The role of endoscopy in the evaluation of suspected choledocholithiasis

    Gastrointest Endosc

    (2010)
  • Y. Meeralam et al.

    Diagnostic accuracy of EUS compared with MRCP in detecting choledocholithiasis: a meta-analysis of diagnostic test accuracy in head-to-head studies

    Gastrointest Endosc

    (2017)
  • S. Kondo et al.

    Detection of common bile duct stones: comparison between endoscopic ultrasonography, magnetic resonance cholangiography, and helical-computed-tomographic cholangiography

    Eur J Radiol

    (2005)
  • V. de Ledinghen et al.

    Diagnosis of choledocholithiasis: EUS or magnetic resonance cholangiography? A prospective controlled study

    Gastrointest Endosc

    (1999)
  • D.S. Early et al.

    Adverse events associated with EUS and EUS with FNA

    Gastrointest Endosc

    (2013)
  • M.I. Canto et al.

    Endoscopic ultrasonography versus cholangiography for the diagnosis of choledocholithiasis

    Gastrointest Endosc

    (1998)
  • F. Prat et al.

    Prospective controlled study of endoscopic ultrasonography and endoscopic retrograde cholangiography in patients with suspected common-bile duct lithiasis

    Lancet

    (1996)
  • J.P. Neoptolemos et al.

    Controlled trial of urgent endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy versus conservative treatment for acute pancreatitis due to gallstones

    Lancet

    (1988)
  • U. Navaneethan et al.

    Delay in performing ERCP and adverse events increase the 30-day readmission risk in patients with acute cholangitis

    Gastrointest Endosc

    (2013)
  • M.A. Khashab et al.

    Delayed and unsuccessful endoscopic retrograde cholangiopancreatography are associated with worse outcomes in patients with acute cholangitis

    Clin Gastroenterol Hepatol

    (2012)
  • L. Chang et al.

    Gallstone pancreatitis: a prospective study on the incidence of cholangitis and clinical predictors of retained common bile duct stones

    Am J Gastroenterol

    (1998)
  • M.E. Cohen et al.

    Prediction of bile duct stones and complications in gallstone pancreatitis using early laboratory trends

    Am J Gastroenterol

    (2001)
  • R. Mounzer et al.

    Comparison of existing clinical scoring systems to predict persistent organ failure in patients with acute pancreatitis

    Gastroenterology

    (2012)
  • V. Chandrasekhara et al.

    Adverse events associated with ERCP

    Gastrointest Endosc

    (2017)
  • S.D. Crockett et al.

    American Gastroenterological Association institute guideline on initial management of acute pancreatitis

    Gastroenterology

    (2018)
  • G. Ersoz et al.

    Biliary sphincterotomy plus dilation with a large balloon for bile duct stones that are difficult to extract

    Gastrointest Endosc

    (2003)
  • J.A. Disario et al.

    Endoscopic balloon dilation compared with sphincterotomy for extraction of bile duct stones

    Gastroenterology

    (2004)
  • P.B. Cotton et al.

    Endoscopic sphincterotomy complications and their management: an attempt at consensus

    Gastrointest Endosc

    (1991)
  • J. Buxbaum et al.

    Randomized trial of cholangioscopy-guided laser lithotripsy versus conventional therapy for large bile duct stones (with videos)

    Gastrointest Endosc

    (2018)
  • P.K. Garg et al.

    Predictors of unsuccessful mechanical lithotripsy and endoscopic clearance of large bile duct stones

    Gastrointest Endosc

    (2004)
  • U. Navaneethan et al.

    Digital, single-operator cholangiopancreatoscopy in the diagnosis and management of pancreatobiliary disorders: a multicenter clinical experience (with video)

    Gastrointest Endosc

    (2016)
  • A. Maydeo et al.

    Single-operator cholangioscopy-guided laser lithotripsy in patients with difficult biliary and pancreatic ductal stones (with videos)

    Gastrointest Endosc

    (2011)
  • S.S. Vege et al.

    Initial medical treatment of acute pancreatitis: American Gastroenterological Association Institute Technical Review

    Gastroenterology

    (2018)
  • D.W. da Costa et al.

    Same-admission versus interval cholecystectomy for mild gallstone pancreatitis (PONCHO): a multicentre randomised controlled trial

    Lancet

    (2015)
  • J.Y. Lau et al.

    Cholecystectomy or gallbladder in situ after endoscopic sphincterotomy and bile duct stone removal in Chinese patients

    Gastroenterology

    (2006)
  • E.M. Targarona et al.

    Randomised trial of endoscopic sphincterotomy with gallbladder left in situ versus open surgery for common bile duct calculi in high-risk patients

    Lancet

    (1996)
  • M.I. Rubin et al.

    Endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis: testing the current guidelines

    Dig Liver Dis

    (2013)
  • M.A. Adams 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)
  • H. He et al.

    Accuracy of ASGE high-risk criteria in evaluation of patients with suspected common bile duct stones

    Gastrointest Endosc

    (2017)
  • F. Tse et al.

    EUS: a meta-analysis of test performance in suspected choledocholithiasis

    Gastrointest Endosc

    (2008)
  • D. Fishman et al.

    Predictors of choledocholithiasis at ERCP in pediatric patients: a report from the Pediatric ERCP Database Initiative (PEDI)

    Gastrointest Endosc

    (2016)
  • J.A. Shea et al.

    What predicts gastroenterologists' and surgeons' diagnosis and management of common bile duct stones?

    Gastrointest Endosc

    (1997)
  • J.C. Figueiredo et al.

    Sex and ethnic/racial-specific risk factors for gallbladder disease

    BMC Gastroenterol

    (2017)
  • M.J. Hall et al.

    Ambulatory surgery data from hospitals and ambulatory surgery centers: United States, 2010

    (2017)
  • S.X. Sun et al.

    Cost-effective decisions in detecting silent common bile duct gallstones during laparoscopic cholecystectomy

    Ann Surg

    (2016)
  • A.F. Peery et al.

    Burden of gastrointestinal, liver, and pancreatic diseases in the United States

    Gastroenterology

    (2015)
  • O.I. Brewer Gutierrez et al.

    Efficacy and safety of digital single-operator cholangioscopy for difficult biliary stones

    Clin Gastroenterol Hepatol

    (2017)
  • A.Y.B. Teoh et al.

    Randomized trial of endoscopic sphincterotomy with balloon dilation versus endoscopic sphincterotomy alone for removal of bile duct stones

    Gastroenterology

    (2013)
  • M.L. Freeman et al.

    Complications of endoscopic biliary sphincterotomy

    N Engl J Med

    (1996)
  • A. Andriulli et al.

    Incidence rates of post-ERCP complications: a systematic survey of prospective studies

    Am J Gastroenterol

    (2007)
  • Cited by (0)

    DISCLOSURE: The following authors disclosed financial relationships relevant to this publication: J. L. Buxbaum: Consultant for Olympus. S. A. Fehmi, P. Yachimski: Consultant for Boston Scientific. L. H. Jamil: Consultant for Aries Pharmaceutical; speaker for Aries Pharmaceutical. M. A. Khashab: Consultant for Boston Scientific Corp, Olympus, and Medtronic; medical advisory board for Boston Scientific Corp and Olympus. N. Thosani, S. B. Wani: Consultant for Boston Scientific Corp and Medtronic. All other authors disclosed no financial relationships relevant to this publication.

    This document was reviewed and approved by the Governing Board of the American Society for Gastrointestinal Endoscopy (ASGE).

    View full text