Scoring system to preoperatively predict choledocholithiasis

Systematic review and meta-analysis of the 2010 ASGE non-invasive predictors of choledocholithiasis and comparison to the 2019 ASGE predictors

In 2019, the American Society for Gastrointestinal Endoscopy (ASGE) guideline on the endoscopic management of choledocholithiasis modified the individual predictors of choledocholithiasis proposed in the widely referenced 2010 guideline to improve predictive performance. Nevertheless, the primary literature, especially for the 2019 iteration, is limited. We performed a systematic review with meta-analysis to examine the diagnostic performance of the 2010, and where possible the 2019, predictors. PROSPERO protocol CRD42020194226. A comprehensive literature search from 2001 to 2020 was performed to identify studies on the diagnostic performance of any of the 2010 and 2019 ASGE choledocholithiasis predictors. Identified studies underwent keyword screening, abstract review, and full-text review. The primary outcomes included multivariate odds ratios (ORs) and 95% confidence intervals for each criterion. Secondary outcomes were reported sensitivities, specificities, and positive and negative predictive value. A total of 20 studies met inclusion criteria. Based on reported ORs, of the 2010 guideline “very strong” predictors, ultrasound with stone had the strongest performance. Of the “strong” predictors, CBD > 6 mm demonstrated the strongest performance. “Moderate” predictors had inconsistent and/or weak performance; moreover, all studies reported gallstone pancreatitis as non-predictive of choledocholithiasis. Only one study examined the new predictor (bilirubin > 4 mg/dL and CBD > 6 mm) proposed in the 2019 guideline. Based on this review, aside from CBD stone on ultrasound, there is discordance between the proposed strength of 2010 choledocholithiasis predictors and their published diagnostic performance. The 2019 guideline appears to do away with the weakest 2010 predictors.

Liver Blood Tests in the Management of Suspected Choledocholithiasis

OBJECTIVE

The likelihood of common bile duct (CBD) stones considers liver blood tests (LBTs) if they are markedly altered only. The aim of our study was to find a reliable tool based on LBTs to predict the presence of CBD stones.

METHODS

We retrospectively considered all patients who underwent magnetic resonance cholangiopancreatography (MRCP) because of suspected CBD stones from January 2014 to June 2019. Demographic, clinical data, and LBT values were collected and analyzed.

RESULTS

We selected 191 patients, 64 (33.5%) with positive MRCP and 127 (66.5%) with negative MRCP. The analysis showed that our compound LBT-based score had 83.6%, 90.7%, and 90.6% sensitivity, specificity, and negative predictive values, respectively, in determining MRCP results.

CONCLUSION

We designed a weighted score with high diagnostic power in determining MRCP results that could help in differentiating between candidates for primary cholecystectomy and patients who benefit from preoperative MRCP.

Combination of CT findings can reliably predict radiolucent common bile duct stones: a novel approach using a CT-based nomogram

OBJECTIVES

To identify CT features that reliably predict the presence of radiolucent common bile duct (CBD) stones.

MATERIALS AND METHODS

This retrospective study included 112 patients (mean age, 60.6 years) with clinically suspected CBD stones that were not visible on CT. All patients had undergone CT followed by endoscopic retrograde cholangiopancreatography (ERCP) to confirm the presence (n = 66) or absence (n = 46) of CBD stones. Two radiologists independently evaluated the CT images. Univariable and multivariable logistic regression analyses were performed to identify demographic, laboratory, and CT predictors for CBD stones. We developed a nomogram based on these results and assessed its performance.

RESULTS

In the multivariate analysis, CBD diameter ≥ 8 mm (odds ratio [OR], 10.12; p < 0.001), pericholecystic fat infiltration (OR, 3.76, p = 0.014), and papillitis (OR, 2.85; p < 0.049) were independent CT predictors of CBD stones. Combination of all three features had a specificity of 100%. Of these features, CBD diameter ≥ 8 mm was the best single predictor. The CT-based nomogram had an area under the curve (AUC) of 0.847 (95% confidence interval [CI], 0.777-0.916) and an accuracy of 77.7% (95% CI, 69.1-84.4%).

CONCLUSIONS

The combination of significant CT features (CBD diameter ≥ 8 mm, pericholecystic fat infiltration, and papillitis) translated into a nomogram allows a reliable estimation of CBD stone presence. It may serve as a decision support tool to determine whether to proceed to further diagnostic tests or treatment option.

KEY POINTS

• CBD diameter ≥ 8 mm (odds ratio [OR] = 10.12, p < 0.001), pericholecystic fat infiltration (OR = 3.76, p = 0.014), and papillitis (OR = 2.85, p = 0.049) were independent predictors of radiolucent CBD stones. • A CBD diameter ≥ 8 mm was the best predictor of CBD stones. • A nomogram based on a combination of these three CT signs predicted the presence of CBD stones and helped classify patients that should go immediately to ERCP, those who require a further investigation, and those who can safely be managed conservatively.