DOWNERS GROVE, Ill. -- June 14, 2019 -- A new Standard of Practice (SOP) document from the American Society for Gastrointestinal Endoscopy (ASGE), “ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis,” provides evidence-based recommendations for the endoscopic evaluation and treatment of bile duct stones.
Bile duct stones are a common clinical problem. In many patients, bile duct stones (choledocholithiasis) can result in obstruction or inflammation of the biliary system or pancreas. Further, choledocholithiasis can result in health problems such as pain, jaundice and infection that can lead to acute pancreatitis, which results in 275,000 hospitalizations annually. These stones most often result from movement of gallstones from the gall bladder into the biliary tree, though there may be other causes including diet, hormones or genetic factors.
Data show that 10 percent of American adults will develop symptomatic gallstones over the course of a decade. More than 700,000 will undergo surgical removal of the gallbladder, and despite 436,000 being managed as outpatients, the annual cost exceeds 6.6 billion dollars.
Endoscopic retrograde cholangiopancreatography (ERCP), a non-surgical procedure performed through an endoscope, is used to diagnose and treat certain problems of the biliary or pancreatic ductal systems; however, this treatment has an adverse event rate of 6 percent to 15 percent.
The guideline looks at several types of endoscopic procedures that may be used for diagnosis; the role of early ERCP in gallstone pancreatitis; various endoscopic approaches for addressing large bile duct stones; and impact of ERCP-guided intraductal therapy for large and difficult stones.
Related aspects of treating this problem are assessed in the guideline; for example, the best timing of ERCP compared with surgery to remove the gall bladder.
According to lead author James Buxbaum, MD, FASGE: “ERCP has transformed bile duct stone removal from a major operation to a minimally invasive procedure. Over the past three decades, numerous endoscopic strategies have been introduced to address even the most difficult bile duct stones. However, because of the risk of adverse events associated with ERCP-guided treatment of bile duct stones, it is important that we identify appropriate candidates for this procedure and reserve biliary endoscopy for patients who have the highest probability of intraductal stones.”
ASGE’s guidelines incorporate evidence-based practice, combining authors’ clinical expertise, patient values, and a rigorous review of clinical studies and research that, collectively, frame the best recommendations for patient care.
The ASGE’s topline recommendations of this guideline include:
- In patients with intermediate risk of choledocholithiasis, we suggest either endoscopic ultrasound (EUS) or Magnetic Resonance Cholangiopancreatography (MRCP) given high specificity; consider factors including patient preference, local expertise, and availability.
In patients with gallstone pancreatitis without cholangitis or biliary obstruction/choledocholithiasis, we recommend against urgent (<48 hours) ERCP.
- In patients with large choledocholithiasis, we suggest performing large balloon dilation after sphincterotomy rather than endoscopic sphincterotomy alone.
For patients with large and difficult choledocholithiasis, we suggest intraductal therapy or conventional therapy with papillary dilation; this may be impacted by local expertise, cost, patient and physician preferences.
This document replaces the ASGE guidelines, “The role of endoscopy in the management of choledocholithiasis,” published in 2011, and “The role of endoscopy in the evaluation of suspected choledocholithiasis,” published in 2010.