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Arif-Tiwari H, Porter KK, Kamel IR, Bashir MR, Fung A, Kaplan DE, McGuire BM, Russo GK, Smith EN, Solnes LB, Thakrar KH, Vij A, Wahab SA, Wardrop RM, Zaheer A, Carucci LR. ACR Appropriateness Criteria® Abnormal Liver Function Tests. J Am Coll Radiol 2023; 20:S302-S314. [PMID: 38040457 DOI: 10.1016/j.jacr.2023.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 08/22/2023] [Indexed: 12/03/2023]
Abstract
Liver function tests are commonly obtained in symptomatic and asymptomatic patients. Various overlapping lab patterns can be seen due to derangement of hepatocytes and bile ducts function. Imaging tests are pursued to identify underlying etiology and guide management based on the lab results. Liver function tests may reveal mild, moderate, or severe hepatocellular predominance and can be seen in alcoholic and nonalcoholic liver disease, acute hepatitis, and acute liver injury due to other causes. Cholestatic pattern with elevated alkaline phosphatase with or without elevated γ-glutamyl transpeptidase can be seen with various causes of obstructive biliopathy. Acute or subacute cholestasis with conjugated or unconjugated hyperbilirubinemia can be seen due to prehepatic, intrahepatic, or posthepatic causes. We discuss the initial and complementary imaging modalities to be used in clinical scenarios presenting with abnormal liver function tests. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Hina Arif-Tiwari
- University of Arizona, Banner University Medical Center, Tucson, Arizona.
| | | | - Ihab R Kamel
- Panel Chair, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Alice Fung
- Oregon Health & Science University, Portland, Oregon
| | - David E Kaplan
- Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania; American Association for the Study of Liver Diseases
| | - Brendan M McGuire
- University of Alabama at Birmingham, Birmingham, Alabama, Primary care physician
| | | | - Elainea N Smith
- University of Alabama at Birmingham Medical Center, Birmingham, Alabama
| | - Lilja Bjork Solnes
- Johns Hopkins Bayview Medical Center, Baltimore, Maryland; Commission on Nuclear Medicine and Molecular Imaging
| | | | - Abhinav Vij
- New York University Langone Medical Center, New York, New York
| | - Shaun A Wahab
- University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Richard M Wardrop
- Cleveland Clinic, Cleveland, Ohio; American College of Physicians, Hospital Medicine
| | | | - Laura R Carucci
- Specialty Chair, Virginia Commonwealth University Medical Center, Richmond, Virginia
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2
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Stock MR, Fine RO, Rivas Y, Levin TL. Magnetic resonance imaging following the demonstration of a normal common bile duct on ultrasound in children with suspected choledocholithiasis: what is the benefit? Pediatr Radiol 2023; 53:358-366. [PMID: 36333493 DOI: 10.1007/s00247-022-05537-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/21/2022] [Accepted: 10/14/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND The role of MRI in evaluating children with an in situ gallbladder and suspected choledocholithiasis following a negative or inconclusive US is unclear. OBJECTIVE To determine whether MRI benefits children with suspected choledocholithiasis and a normal common bile duct (CBD) without stones on US. MATERIALS AND METHODS We conducted a retrospective 10-year review of paired US and MRI (within 10 days) in children 18 years or younger with suspected choledocholithiasis. With MRI as a reference standard, two reviewers independently evaluated the images for CBD diameter, choledocholithiasis, cholelithiasis and pancreatic edema. Serum lipase was recorded. We calculated exact binomial confidence limits for test positive predictive values (PPVs) and negative predictive values (NPVs) using R library epiR. RESULTS Of 87 patients (46 female, 41 male; mean age 14 years, standard deviation [SD] 4.6 years; mean interval between US and MRI 1.6 days, SD 1.8 days), 55% (48/87) had true-negative US, without CBD dilation/stones confirmed on MRI; 5% (4/87) had false-positive US showing CBD dilatation without stones, not confirmed on MRI; 33% (29/87) had true-positive US, with MRI confirming CBD dilatation; and 7% (6/87) had false-negative US, where MRI revealed CBD stones without dilatation (2 patients) and CBD dilatation with or without stones (4 patients). Patients with false-negative US had persistent or worsening symptoms, pancreatitis or SCD. The overall US false-negative rate was 17% (6/35). Normal-caliber CBD on US without stones had an NPV of 89% (48/54, 95% confidence interval: 0.77-0.96). CONCLUSION MRI adds little information in children with a sonographically normal CBD except in the setting of pancreatitis or worsening clinical symptoms. Further evaluation is warranted in children with elevated risk of stone disease.
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Affiliation(s)
- Miriam R Stock
- Medical Program, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Rona Orentlicher Fine
- Division of Pediatric Radiology, Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th St., Bronx, NY, 10467, USA
| | - Yolanda Rivas
- Division of Pediatric Gastroenterology, Department of Pediatrics, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Terry L Levin
- Division of Pediatric Radiology, Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th St., Bronx, NY, 10467, USA.
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Tunruttanakul S, Verasmith K, Patumanond J, Mingmalairak C. Development of a Predictive Model for Common Bile Duct Stones in Patients With Clinical Suspicion of Choledocholithiasis: A Cohort Study. Gastroenterology Res 2022; 15:240-252. [PMID: 36407811 PMCID: PMC9635785 DOI: 10.14740/gr1560] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 09/14/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Current choledocholithiasis guidelines heavily focus on patients with low or no risk, they may be inappropriate for populations with high rates of choledocholithiasis. We aimed to develop a predictive scoring model for choledocholithiasis in patients with relevant clinical manifestations. METHODS A multivariable predictive model development study based on a retrospective cohort of patients with clinical suspicion of choledocholithiasis was used in this study. The setting was a 700-bed public tertiary hospital. Participants were patients who had completed three reference tests (endoscopic retrograde cholangiography, magnetic resonance cholangiopancreatography, and intraoperative cholangiography) from January 2019 to June 2021. The model was developed using logistic regression analysis. Predictor selection was conducted using a backward stepwise approach. Three risk groups were considered. Model performance was evaluated by area under the receiver operating characteristic curve, calibration, classification measures, and decision curve analyses. RESULTS Six hundred twenty-one patients were included; the choledocholithiasis prevalence was 59.9%. The predictors were age > 55 years, pancreatitis, cholangitis, cirrhosis, alkaline phosphatase level of 125 - 250 or > 250 U/L, total bilirubin level > 4 mg/dL, common bile duct size > 6 mm, and common bile duct stone detection. Pancreatitis and cirrhosis each had a negative score. The sum of scores was -4.5 to 28.5. Patients were categorized into three risk groups: low-intermediate (score ≤ 5), intermediate (score 5.5 - 14.5), and high (score ≥ 15). Positive likelihood ratios were 0.16 and 3.47 in the low-intermediate and high-risk groups, respectively. The model had an area under the receiver operating characteristic curve of 0.80 (95% confidence interval: 0.76, 0.83) and was well-calibrated; it exhibited better statistical suitability to the high-prevalence population, compared to current guidelines. CONCLUSIONS Our scoring model had good predictive ability for choledocholithiasis in patients with relevant clinical manifestations. Consideration of other factors is necessary for clinical application, particularly regarding the availability of expert physicians and specialized equipment.
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Affiliation(s)
- Suppadech Tunruttanakul
- Department of Surgery, Sawanpracharak Hospital, Nakhon Sawan 60000, Thailand,Corresponding Author: Suppadech Tunruttanakul, Department of Surgery, Sawanpracharak Hospital, Muang, Nakhon Sawan 60000, Thailand.
| | | | - Jayanton Patumanond
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Chatchai Mingmalairak
- Department of Surgery, Faculty of Medicine, Thammasat University, Pathum Thani 10120, Thailand
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Tracy BM, Poulose BK, Paterson CW, Mendoza AE, Gaitanidis A, Saxe JM, Young AJ, Zielinski MD, Sims CA, Gelbard RB. National adherence to the ASGE-SAGES guidelines for managing suspected choledocholithiasis: An EAST multicenter study. J Trauma Acute Care Surg 2022; 92:305-312. [PMID: 34813581 DOI: 10.1097/ta.0000000000003466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The American Society for Gastrointestinal Endoscopy and Society of American Gastrointestinal and Endoscopic Surgeons provide guidelines for managing suspected common bile duct (CBD) stones. We sought to evaluate adherence to the guidelines among patients with choledocholithiasis and/or acute biliary pancreatitis (ABP) and to evaluate the ability of these guidelines to predict choledocholithiasis. METHODS We prospectively identified patients undergoing same-admission cholecystectomy for choledocholithiasis and/or ABP from 2016 to 2019 at 12 United States medical centers. Predictors of suspected CBD stones were very strong (CBD stone on ultrasound; bilirubin >4 mg/dL), strong (CBD > 6 mm; bilirubin ≥1.8 to ≤4 mg/dL), or moderate (abnormal liver function tests other than bilirubin; age >55 years; ABP). Patients were grouped by probability of CBD stones: high (any very strong or both strong predictors), low (no predictors), or intermediate (any other predictor combination). The management of each probability group was compared with the recommended management in the guidelines. RESULTS The cohort was comprised of 844 patients. High-probability patients had 64.3% (n = 238/370) deviation from guidelines, intermediate-probability patients had 29% (n = 132/455) deviation, and low-probability patients had 78.9% (n = 15/19) deviation. Acute biliary pancreatitis increased the odds of deviation for the high- (odds ratio [OR], 1.71; 95% confidence interval [CI], 1.06-2.8; p = 0.03) and intermediate-probability groups (OR, 1.6; 95% CI, 1.07-2.42; p = 0.02). Age older than 55 years (OR, 2.19; 95% CI, 1.4-3.43; p < 0.001) also increased the odds of deviation for the intermediate group. A CBD greater than 6 mm predicted choledocholithiasis in the high (adjusted OR (aOR), 2.16; 95% CI, 1.17-3.97; p = 0.01) and intermediate group (aOR, 2.78; 95% CI, 1.59-4.86; p < 0.001). Any very strong predictor (aOR, 2.43; 95% CI, 1.76-3.37; p < 0.0001) and both strong predictors predicted choledocholithiasis (aOR, 2; 95% CI, 1.35-2.96; p < 0.001). CONCLUSION Almost 45% of patients with suspected CBD stones were managed discordantly from the American Society for Gastrointestinal Endoscopy and Society of American Gastrointestinal and Endoscopic Surgeons guidelines. We believe these guidelines warrant revision to better reflect the ability of the clinical variables at predicting choledocholithiasis. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Brett M Tracy
- From the Division of Trauma, Critical Care & Burn Surgery (B.M.T., B.K.P., A.J.Y., C.A.S.), The Ohio State University, Columbus, Ohio; Department of Surgery (C.W.P.), Emory University School of Medicine; Division of Acute Care Surgery (C.W.P., R.B.G.), Grady Memorial Hospital, Atlanta, Georgia; Division of Trauma, Emergency Surgery & Surgical Critical Care (A.E.M., A.G.), Massachusetts General Hospital, Boston, Massachusetts; Department of Surgery (J.M.S.), Ascension St. Vincent Hospital, Indianapolis, Indiana; Division of Trauma (M.D.Z.), Critical Care & Emergency General Surgery, Mayo Clinic, Rochester, Minnesota; and Division of Acute Care Surgery (R.B.G.), University of Alabama at Birmingham, Birmingham, Alabama
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Samara O, Azzam MI, Alshrouf MA, Khanfar AN, Mohialdeen RR, Barham OF, Barham MF, AlRyalat SA. Diagnostic accuracy of ultrasonography compared with magnetic resonance cholangiopancreatography in the detection of choledocholithiasis. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:247-253. [PMID: 34995366 DOI: 10.1002/jcu.23136] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 11/11/2021] [Accepted: 12/03/2021] [Indexed: 06/14/2023]
Abstract
PURPOSE The aim of this study is to compare the diagnostic accuracy of ultrasonography (US) with magnetic resonance cholangiopancreatography (MRCP) in the diagnosis of choledocholithiasis in context of laboratory blood test values. METHODS This retrospective study included patients who underwent both MRCP and US as part of their choledocholithiasis workup. MRCP findings, reviewed by two board-certified radiologists, laboratory findings, and US reports were collected. RESULTS Our study included 243 patients. On US examination 74 cases were found dilated (30.5%), while 94 cases showed dilation (38.7%) by MRCP. The overall accuracy of US was 76.1%, where 185 patients had similar MRCP and US findings, 7.8% had false positive ultrasound, and 16% had false negative ultrasound finding. The accuracy of ultrasound was significantly higher in males (p = .013). In addition, a significant difference in duct dilatation as found by ultrasound and accuracy of diagnosis (p = .01). CONCLUSION Although US has a relatively low accuracy, its properties of being cost-effective and non-invasive make it an ideal first step in the diagnosis of choledocholithiasis. If a patient has elevated liver enzymes or a high risk of choledocholithiasis, we recommend that MRCP be performed even no dilation was seen on US.
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Affiliation(s)
- Osama Samara
- Department of Radiology and Nuclear Medicine, The University of Jordan, Amman, Jordan
| | - Muayad I Azzam
- School of Medicine, The University of Jordan, Amman, Jordan
| | | | - Asim N Khanfar
- School of Medicine, The University of Jordan, Amman, Jordan
| | - Rand Rafid Mohialdeen
- Department of Radiology and Nuclear Medicine, The University of Jordan, Amman, Jordan
| | - Ola Fawwaz Barham
- Department of Radiology and Nuclear Medicine, The University of Jordan, Amman, Jordan
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Pareek T, R R, R P, Chidambaranathan S, O L NB. A Single Centre Experience With Routine Magnetic Resonance Cholangiopancreatography in the Management of Patients With Gall Stone Disease. Cureus 2021; 13:e18743. [PMID: 34790490 PMCID: PMC8588194 DOI: 10.7759/cureus.18743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2021] [Indexed: 11/05/2022] Open
Abstract
AIM To evaluate the role of preoperative magnetic resonance cholangiopancreatography (MRCP) in detection of common bile duct stone (CBDS) in cases of gall stone disease (GSD). METHODS This is a retrospective study with a prospectively maintained database, carried out in 116 patients who underwent laparoscopic cholecystectomy (LC) for GSD, from October 2017 to September 2020. Preoperative MRCP was performed in all cases. RESULTS MRCP detected CBDS in 23 out of 116 patients (19.8%) including silent CBDS in seven patients (6%). In situations of normal biochemical parameters and USG abdomen, 30.4% unnoticed CBDS out of all 23 CBDS, were discovered by MRCP. The sensitivity and specificity of aspartate aminotransferase (AST) or alanine aminotransferase (ALT) [positive predictive value (PPV): 24%; negative predictive value (NPV): 81.3%], alkaline phosphatase (ALP) (PPV: 63.2%; NPV: 88.7%), serum total bilirubin (PPV: 57.1%; NPV: 88.4%) and CBD diameter (PPV: 61.5%; NPV: 85.4%) were, respectively, 26.1% and 79.6%, 52.2% and 92.5%, 52.2% and 90.3%, and 34.8% and 94.6%. Cystic duct variations found in nine patients (7.75%). There was no bile duct injury (0%) noted in post operative patients. CONCLUSION With normal biochemical and USG parameters, MRCP is a valuable non-invasive investigation to detect the overlooked CBDS. After recognising the cystic duct variants, it may be possible to prevent bile duct injury. Before performing a laparoscopic cholecystectomy (LC) in GSD, a routine preoperative MRCP is highly recommended.
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Affiliation(s)
- Tanmay Pareek
- Surgical Gastroenterology, Madras Medical College, Chennai, IND
| | - Rajkumar R
- Surgical Gastroenterology, Madras Medical College, Chennai, IND
| | - Prabhakaran R
- Surgical Gastroenterology, Madras Medical College, Chennai, IND
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Cohen RZ, Tian H, Sauer CG, Willingham FF, Santore MT, Mei Y, Freeman AJ. Creation of a Pediatric Choledocholithiasis Prediction Model. J Pediatr Gastroenterol Nutr 2021; 73:636-641. [PMID: 34224492 DOI: 10.1097/mpg.0000000000003219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Definitive non-invasive detection of pediatric choledocholithiasis could allow more efficient identification of those patients who are most likely to benefit from therapeutic endoscopic retrograde cholangiopancreatography (ERCP) for stone extraction. OBJECTIVE To craft a pediatric choledocholithiasis prediction model using a combination of commonly available serum laboratory values and ultrasound results. METHODS A retrospective review of laboratory and imaging results from 316 pediatric patients who underwent intraoperative cholangiogram or ERCP due to suspicion of choledocholithiasis were collected and compared to presence of common bile duct stones on cholangiography. Multivariate logistic regression with supervised machine learning was used to create a predictive scoring model. Monte-Carlo cross-validation was used to validate the scoring model and a score threshold that would provide at least 90% specificity for choledocholithiasis was determined in an effort to minimize non-therapeutic ERCP. RESULTS Alanine aminotransferase (ALT), total bilirubin, alkaline phosphatase, and common bile duct diameter via ultrasound were found to be the key clinical variables to determine the likelihood of choledocholithiasis. The dictated specificity threshold of 90.3% yielded a sensitivity of 40.8% and overall accuracy of 71.5% in detecting choledocholithiasis. Positive predictive value was 71.4% and negative predictive value was 72.1%. CONCLUSION Our novel pediatric choledocholithiasis predictive model is a highly specific tool to suggest ERCP in the setting of likely choledocholithiasis.
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Affiliation(s)
- Reuven Zev Cohen
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Emory University School of Medicine, Children's Healthcare of Atlanta
| | - Hongzhen Tian
- H. Milton School of Industrial and Systems Engineering, Georgia Institute of Technology
| | - Cary G Sauer
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Emory University School of Medicine, Children's Healthcare of Atlanta
| | - Field F Willingham
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine
| | - Matthew T Santore
- Section of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
| | - Yajun Mei
- H. Milton School of Industrial and Systems Engineering, Georgia Institute of Technology
| | - A Jay Freeman
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Emory University School of Medicine, Children's Healthcare of Atlanta
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Alhaddad O, Elsabaawy M, Hendy O, Kamal A, Elshazly H. A unique case of black choledocholithiasis: a video-based case review in the Pancreato-Biliary Division–Endoscopy Unit of National Liver Institute (NLI). EGYPTIAN LIVER JOURNAL 2021. [DOI: 10.1186/s43066-021-00114-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Black gall stones are consistently described in relation to haem turnover and hemolytic disorders. Black gall stones are also a frequent presentation in cirrhotic patients, principally due to hemolysis-related hypersplenism.
Case presentation
Herein, we present a case of an average built 83-year-old lady who was suffering from biliary-type abdominal episodes of pain. Neither clinical nor laboratory evidence of overt biliary obstruction, cholangitis, or pancreatitis was detected. Sonographic examination revealed the presence of calcular gall bladder with many small stones, dilated common bile duct (CBD), and biliary radicles, along with homogenous average-sized liver, average-sized spleen with normal echogenicity and no focal lesions. Endoscopic retrograde cholangiography (ERC) was performed with wide papillotomy which was surprisingly followed by a drift of innumerable intensely black small stones.
Conclusion
In aged population, absence of the full-blown clinical syndrome in relation to complicated CBD stones should not exclude endoscopic intervention.
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Argiriov Y, Dani M, Tsironis C, Koizia LJ. Cholecystectomy for Complicated Gallbladder and Common Biliary Duct Stones: Current Surgical Management. Front Surg 2020; 7:42. [PMID: 32793627 PMCID: PMC7385246 DOI: 10.3389/fsurg.2020.00042] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 06/08/2020] [Indexed: 12/12/2022] Open
Abstract
Gallstone disease accounts for the vast majority of acute surgical admissions in the UK, with a major treatment being cholecystectomy. Practice varies significantly as to whether surgery is performed during the acute symptomatic phase, or after a period of recovery. Differences in practice relate to operative factors, patient factors, surgeon factors and hospital and trust wide policies. In this review we summarize recent evidence on management of gallstone disease, particularly with respect to whether cholecystectomy should occur during index presentation or following recovery. We highlight morbidity and mortality studies, cost, and patient reported outcomes. We speculate on barriers to change in service delivery. Finally, we propose potential solutions to optimize care.
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Affiliation(s)
- Yanna Argiriov
- Cutrale Perioperative and Ageing Research Group, Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Melanie Dani
- Cutrale Perioperative and Ageing Research Group, Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Christos Tsironis
- Department of Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Louis J Koizia
- Cutrale Perioperative and Ageing Research Group, Department of Bioengineering, Imperial College London, London, United Kingdom
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An Update on Hepatobiliary Ultrasound. CURRENT RADIOLOGY REPORTS 2020. [DOI: 10.1007/s40134-020-00357-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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11
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Zhang J, Wang J, Yu H, Wang G, Zhang J, Zhu R, Liu X, Li J. Comparison between Atorvastatin and Rosuvastatin on Secondary Percutaneous Coronary Intervention Rate and the Risk Factors in Patients with Coronary Heart Disease. Curr Drug Metab 2020; 21:818-828. [PMID: 32156233 DOI: 10.2174/1389200221666200310110410] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 12/29/2019] [Accepted: 01/06/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The aim is to compare atorvastatin versus rosuvastatin on secondary percutaneous coronary intervention (PCI) rate and explore risk factors in coronary heart disease (CHD) patients. METHODS A cohort study with 283 CHD subjects was launched from 2011 to 2015. Cox proportional hazards regression model, Receiver Operating Characteristic (ROC) and nomogram were used to compare the effect of atorvastatin and rosuvastatin on secondary PCI rate and disease risk factors. Even why the two statins had different effects based on gene expression profile analysis has been explored. RESULTS Gene FFA (Freely fatty acid), AST (Aspartate Transaminase) and ALT (Alanine transaminase) showed the statistical difference between the four statin groups (P<0.05). In the AA group (Continuous Atorvastatin usage), albumin was a risk factor (Hazard Ratio (HR):1.076, 95%CI (1.001, 1.162), p<0.05). In the AR group (Start with Atorvastatin usage, then change to Rosuvastatin usage), ApoA was a protective factor (HR:0.004, 95%CI (0.001, 0.665), p<0.05). GLB (Galactosidase Beta) was a risk factor (HR:1.262, 95%CI (1.010, 1.576), p<0.05). In RR group (Continuous Rosuvastatin usage), ApoE was a protective factor (HR:0.943, 95%CI (0.890, 1.000), <0.05). ALT was a risk factor (HR:1.030, 95%CI (1.000, 1.060), p<0.05). CONCLUSION Patients in the RA group had the lowest secondary PCI rate. ALT was a risk factor in the RR group. Gene Gpt (Glutamic Pyruvic Transaminase) encoded for one subtype of ALT had a significantly different expression in different statin groups.
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Affiliation(s)
- Jie Zhang
- Department of Cardiology, Shanghai Tongji Hospital Affiliated to Tongji University School of Medicine, Shanghai, 200065, China
| | - Jiaqi Wang
- Institute of Clinical Epidemiology and Evidence-based Medicine, Tongji University School of Medicine, Shanghai, 200092, China
| | - Han Yu
- Department of Cardiology, Shanghai Tongji Hospital Affiliated to Tongji University School of Medicine, Shanghai, 200065, China
| | - Guanghua Wang
- Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, 201204, China
| | - Junfang Zhang
- Institute of Clinical Epidemiology and Evidence-based Medicine, Tongji University School of Medicine, Shanghai, 200092, China
| | - Rui Zhu
- Department of Cardiology, Shanghai Tongji Hospital Affiliated to Tongji University School of Medicine, Shanghai, 200065, China
| | - Xuebo Liu
- Department of Cardiology, Shanghai Tongji Hospital Affiliated to Tongji University School of Medicine, Shanghai, 200065, China
| | - Jue Li
- Department of Cardiology, Shanghai Tongji Hospital Affiliated to Tongji University School of Medicine, Shanghai, 200065, China
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Chen H, Jorissen R, Walcott J, Nikfarjam M. Incidence and predictors of common bile duct stones in patients with acute cholecystitis: a systematic literature review and meta‐analysis. ANZ J Surg 2019; 90:1598-1603. [DOI: 10.1111/ans.15565] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 09/16/2019] [Accepted: 09/18/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Hongyi Chen
- Department of Surgery The University of Melbourne, Austin Health Melbourne Victoria Australia
| | - Robert Jorissen
- Systems Biology and Personalised Medicine Division Walter and Eliza Hall Institute of Medical Research Melbourne Victoria Australia
| | - James Walcott
- Department of Surgery The University of Melbourne, Austin Health Melbourne Victoria Australia
| | - Mehrdad Nikfarjam
- Department of Surgery The University of Melbourne, Austin Health Melbourne Victoria Australia
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Ding H, Zhou P, Xu M, Chen W, Li Q, Chen T, Cai M, Chen T, Lian J, Zhang Y. Combining endoscopic ultrasound and tumor markers improves the diagnostic yield on the etiology of common bile duct dilation secondary to periampullary pathologies. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:314. [PMID: 31475184 DOI: 10.21037/atm.2019.06.51] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background Unexplained common bile duct (CBD) dilatation may be caused by many etiologies, such as periampullary tumors, a pancreatic neoplasm, choledocholithiasis or an inflammatory stenosis. The aim of this study is to evaluate the diagnostic yield of endoscopic ultrasonography (EUS) in patients with unexplained CBD dilatation, in combination with tumor markers, liver chemistry, symptoms, surgical history and whether there is dilatation of the pancreatic duct (PD). Methods From January 2016 to July 2017, 115 patients were referred for EUS in our center for CBD dilatation of an unknown etiology. A treatment plan is made based on the EUS result combined with the other clinical information. The final diagnosis is determined by surgical histology or follow-up of at least 3 months. Results The sensitivity, specificity and accuracy of EUS for patients with choledocholithiasis were 100.0% (10/10), 100.0% (105/105) and 100.0% (115/115), respectively. The sensitivity, specificity and accuracy of EUS for patients with periampullary tumor were 86.5% (32/37), 89.7% (70/78) and 88.7% (102/115), respectively. The sensitivity, specificity and accuracy of EUS for patients with inflammatory stenosis were 88.2% (60/68), 89.4% (42/47) and 88.7% (102/115), respectively. The overall accuracy of EUS for diagnosing an undetermined etiology for CBD dilatation was 88.7% (102/115) and was higher than the accuracy of ultrasound (US) (64.1%), computed tomography (CT) (66.2%), magnetic resonance imaging (MRI) (67.0%) or PET-CT (66.0%). The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of EUS combined with tumor markers for patients with malignant dilatation of CBD were 91.9% (34/37), 97.4% (76/78), 94.4% (34/36), 96.2% (76/79) and 95.7% (110/115), respectively. PD dilation (P=0.026) and weight loss (P=0.035) had significant predictive values of malignancy. Conclusions EUS is an effective diagnostic tool for determining the etiology of a CBD dilatation, and offers meaningful information for guiding a treatment plan. EUS used in conjunction with tumor markers has high yield in differentiating benign and malignant CBD dilatation. More attention should be paid to patients with PD dilation or weight loss to prevent misdiagnosis of malignant CBD dilation.
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Affiliation(s)
- Han Ding
- Department of General Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China
| | - Pinghong Zhou
- Endoscopy center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Meidong Xu
- Endoscopy center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Weifeng Chen
- Endoscopy center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Quanlin Li
- Endoscopy center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Tao Chen
- Endoscopy center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Mingyan Cai
- Endoscopy center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Tianyin Chen
- Endoscopy center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Jingjing Lian
- Endoscopy center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Yiqun Zhang
- Endoscopy center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai 200032, China
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Luo Y, Yang T, Yu Q, Zhang Y. Laparoscopic Ultrasonography Versus Magnetic Resonance Cholangiopancreatography in Laparoscopic Surgery for Symptomatic Cholelithiasis and Suspected Common Bile Duct Stones. J Gastrointest Surg 2019; 23:1143-1147. [PMID: 30187333 DOI: 10.1007/s11605-018-3949-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 08/23/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND There continues to be controversy regarding the optimal screening modality in patients with symptomatic cholelithiasis and suspected common bile duct (CBD) stones. The aim of this study was to assess the diagnostic accuracy of laparoscopic ultrasonography (LUS) compared to magnetic resonance cholangiopancreatography (MRCP). METHODS Both LUS and MRCP were performed to evaluate the CBD stones and biliary anatomy in 200 patients undergoing laparoscopic surgery. Pre-, intra-, and postoperative data were collected prospectively and reviewed retrospectively. RESULTS Coexisting CBD stones were identified in 64 of 200 (32%) patients by surgical exploration or postoperative ERCP. For the detection of CBD stones, LUS yielded a positive predictive value of 100%, a negative predictive value of 99.3%, a sensitivity of 98.4%, and a specificity of 100%. Preoperative MRCP had a positive predictive value of 87.9%, a negative predictive value of 95.5%, a sensitivity of 90.6%, and a specificity of 94.1%. The non-random concordance between MRCP and LUS was considered to be excellent with a kappa coefficient of 0.92 (p < 0.01). CONCLUSIONS LUS can reduce the need for MRCP examination and can become the primary imaging method for the evaluation of CBD stones in laparoscopic surgery.
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Affiliation(s)
- Ying Luo
- Department of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing, 100853, China.
| | - Tao Yang
- Department of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing, 100853, China
| | - Qiang Yu
- Department of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing, 100853, China
| | - Yu Zhang
- Department of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing, 100853, China
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15
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Gillaspie DB, Davis KA, Schuster KM. Total bilirubin trend as a predictor of common bile duct stones in acute cholecystitis and symptomatic cholelithiasis. Am J Surg 2018; 217:98-102. [PMID: 29929909 DOI: 10.1016/j.amjsurg.2018.06.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 06/06/2018] [Accepted: 06/14/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND We hypothesized that trends in total bilirubin in the context of cholecystitis and symptomatic cholelithiasis could be used to guide testing for the presence of common bile duct stones (CBDS). METHODS A review of adult patients with acute cholecystitis or biliary colic with elevated total bilirubin and at least two levels drawn prior to procedural intervention was performed. Trends of total bilirubin and other serum makers were examined to predict the presence of CBDS. RESULTS The total bilirubin level at presentation, average over 24 h and average over 48 h (3.74 mg/dl vs. 2.29 mg/dl, p = 0.005; 3.72 mg/dl vs. 2.40 mg/dl, p = 0.009; 2.41 mg/dl vs. 1.47 mg/dl, p < 0.001) respectively, were all higher in those with CBDS. However, prediction was not improved by following levels over time. CONCLUSION Patients presenting with elevated serum bilirubin, should undergo immediate imaging or procedural intervention rather than obtaining follow-up bilirubin levels.
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Affiliation(s)
- Devin B Gillaspie
- Yale School of Medicine, Department of Trauma, Surgical Critical Care and Surgical Emergencies, New Haven, CT, USA
| | - Kimberly A Davis
- Yale School of Medicine, Department of Trauma, Surgical Critical Care and Surgical Emergencies, New Haven, CT, USA
| | - Kevin M Schuster
- Yale School of Medicine, Department of Trauma, Surgical Critical Care and Surgical Emergencies, New Haven, CT, USA.
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Aleknaite A, Simutis G, Stanaitis J, Valantinas J, Strupas K. Risk assessment of choledocholithiasis prior to laparoscopic cholecystectomy and its management options. United European Gastroenterol J 2017; 6:428-438. [PMID: 29774157 DOI: 10.1177/2050640617731262] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 08/12/2017] [Indexed: 12/15/2022] Open
Abstract
Background Accurate risk evaluation of choledocholithiasis prior to laparoscopic cholecystectomy is essential to determine optimal management strategy. Objective Our study aimed to evaluate the accuracy of separate predictors and Vilnius University Hospital Index (VUHI = A/30 + 0.4 × B; A = total bilirubin concentration (µmol/l), B = common bile duct (CBD) diameter (mm) measured by ultrasound) diagnosing choledocholithiasis and to assess different management strategies (cholecystectomy with intraoperative cholangiography and endoscopic retrograde cholangiopancreatography (ERCP)). Methods The retrospective study included 350 patients admitted to a tertiary care centre for laparoscopic cholecystectomy for cholecystolithiasis who were investigated for concomitant choledocholithiasis. Results Choledocholithiasis was diagnosed in 182 (76.2%) cases in the high-risk group (VUHI value ≥4.7) and 44 (39.6%) in the low, odds ratio is 4.86 (95% CI: 3.00-7.88). Its sensitivity was 80.5%, specificity 54.0%, accuracy 71.1%. Dilated CBD had the highest sensitivity (92.5%) of predictors.ERCP showed better diagnostic performance than intraoperative cholangiography. Complications of ERCP were more frequent for patients without stones. There was no significant difference of outcomes between the two management strategies. Conclusion The prognostic index has good diagnostic accuracy but dividing patients into two risk groups is insufficient. The suggested model allows determining an intermediate-risk group, which requires additional investigation. Both management approaches are appropriate.
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Affiliation(s)
- Ausra Aleknaite
- Department of Endoscopic Diagnostics and Minimally Invasive Surgery, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania.,Clinic of Gastroenterology, Nephrourology and Surgery, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Gintaras Simutis
- Clinic of Gastroenterology, Nephrourology and Surgery, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.,Centre of Abdominal Surgery, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Juozas Stanaitis
- Department of Endoscopic Diagnostics and Minimally Invasive Surgery, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania.,Clinic of Gastroenterology, Nephrourology and Surgery, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Jonas Valantinas
- Centre of Abdominal Surgery, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania.,Centre of Hepatology, Gastroenterology and Dietetics, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Kestutis Strupas
- Clinic of Gastroenterology, Nephrourology and Surgery, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.,Centre of Abdominal Surgery, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
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Abstract
BACKGROUND Patients with gallstone disease can present with elevated liver function tests (LFTs). It is often challenging to differentiate those with a common bile duct (CBD) stone from those without a CBD stone on the basis of the LFTs levels. In this study, we aim to evaluate the predictors of a CBD stones among patients presenting with symptomatic gallbladder disease and elevated LFTs. PATIENTS AND METHODS We retrospectively examined all patients who had undergone a cholecystectomy between January 2010 and December 2015. Patients with symptomatic cholelithiasis and increased LFTs were included. Patient characteristics, imaging findings, lab findings, endoscopic interventions, and operative report were recorded and evaluated. The diagnosis of CBD stones was made on the basis of ERCP and IOC findings. RESULTS We included 354 patients in the final analysis. Of these, 113 (32%) had confirmed choledocholithiasis. The prevalence of CBD stones among biliary colic, acute cholecystitis, and pancreatitis patients was 47, 25, and 26%, respectively. γ-Glutamyl transferase and direct bilirubin had the highest sensitivities for CBD stones among these patients (83 vs. 79%). In the setting of biliary colic, total bilirubin was highly predictive of CBD stones with a positive predictive value of 85%. In the setting of acute cholecystitis, elevated LFTs were even less significant in predicting stones, with a positive predictive value of less than 40% for most. CONCLUSION Although γ-glutamyl transferase and bilirubin levels showed a relatively higher sensitivity for CBDS compared with the other LFTs, these were not reliable enough because of high false-positive as well as false-negative values, especially in patients presenting with acute cholecystitis.
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18
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Kaif M, Agrawal D, Sreenarasimhaiah J. Can clinical factors predict the need for intervention after a positive intraoperative cholangiogram? J Dig Dis 2017; 18:410-415. [PMID: 28547873 DOI: 10.1111/1751-2980.12488] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Revised: 05/20/2017] [Accepted: 05/23/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To determine whether clinical factors such as the elevation or decline of biochemical liver tests and bile duct dilation can help to identify patients who will truly benefit from therapeutic endoscopic retrograde cholangiopancreatography (ERCP) following a positive intraoperative cholangiography (IOC) study. METHODS All cholecystectomies during a 3-year period were examined retrospectively for positive intraoperative cholangiograms. Sonographic findings of bile duct dilation and transaminase levels at admission, including trends during the course of hospitalization and prior to ERCP, were evaluated. RESULTS Of 369 patients with intraoperative cholangiogram studies, 80 (21.7%) were positive. Prior to surgery, a sonogram showed biliary dilation in 50 (62.5%) and ERCP demonstrated actual stones in 27 (61.4%) out of 44 patients. In 24 patients with persistent elevation in transaminases and no biliary dilation, ERCP revealed stones in 12 (50.0%). Sonographic finding of biliary dilation had a positive predictive value (PPV) of 61.4% and a negative predictive value (NPV) of 60.0%. Persistent elevation in transaminases had a PPV of 59.3%. A 50% decline in transaminases had a NPV of 41.2%. Overall, only 39 (48.8%) of all patients with a positive intraoperative cholangiogram study required therapeutic ERCP. CONCLUSIONS Elevated transaminases and sonographic biliary dilation have poor predictive values for choledocholithiasis. Thus, patients with a positive intraoperative cholangiogram may benefit from additional studies, such as endoscopic ultrasound or magnetic resonance cholangiopancreatography prior to ERCP.
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Affiliation(s)
- Mohammed Kaif
- Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Deepak Agrawal
- Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jayaprakash Sreenarasimhaiah
- Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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20
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Chiang PH, Lai KH, Tsai TJ, Lin KH, Wang KM, Kao SS, Sun WC, Cheng JS, Hsu PI, Tsai WL, Chen WC, Li YD, Wang EM, Lin HS, Chan HH. Is endoscopic treatment beneficial in patients with clinically suspicious of common bile duct stones but no obvious filling defects during the ERCP examination? BMC Gastroenterol 2016; 16:102. [PMID: 27565889 PMCID: PMC5002136 DOI: 10.1186/s12876-016-0524-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 08/16/2016] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Sometimes, no definite filling defect could be found by cholangiogram (ERC) during the endoscopic retrograde cholangio-pancreatiographic (ERCP) exam; even prior images had evidence of common bile duct stones (CBDS). We aimed in estimating the positive rate of extraction of CBDS who had treated by endoscopic sphincterotomy/endoscopic papillary balloon dilation (EST/EPBD) with negative ERC finding. METHODS One hundred forty-one patients with clinically suspicious of CBDS but negative ERC, who had received EST/EPBD treatments was enrolled. Potential factors for predicting CBDS, as well as the treatment-related complications were analyzed. RESULTS Nearly half of the patients with negative ERC, had a positive stone extraction. Only patients with high probability of CBDS were significantly associated with positive stone extraction. Moreover, patients with intermediate probability of CBDS had higher rates of overall complications, including post-ERCP pancreatitis. In addition, no significant difference of post-ERCP pancreatitis was found between EST and EPBD groups in any one group of patients with the same probability of CBDS. CONCLUSIONS Regarding patients with negative ERC, therapeutic ERCP is beneficial and safe for patients present with high probability of CBDS. Moreover, under the same probability of CBDS, there was no significance difference in post-ERCP pancreatitis between EST and EPBD.
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Affiliation(s)
- Po-Hung Chiang
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, 386 Ta-Chung 1st Road, Kaohsiung, 81362 Taiwan
| | - Kwok-Hung Lai
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, 386 Ta-Chung 1st Road, Kaohsiung, 81362 Taiwan
- School of Medicine, National Yang-Ming University, No. 155, Sec. 2, Li-Nong Street, Pei-Tou, Taipei, 112 Taiwan
| | - Tzung-Jiun Tsai
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, 386 Ta-Chung 1st Road, Kaohsiung, 81362 Taiwan
| | - Kung-Hung Lin
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, 386 Ta-Chung 1st Road, Kaohsiung, 81362 Taiwan
| | - Kai-Ming Wang
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, 386 Ta-Chung 1st Road, Kaohsiung, 81362 Taiwan
| | - Sung-Shuo Kao
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, 386 Ta-Chung 1st Road, Kaohsiung, 81362 Taiwan
- School of Medicine, National Yang-Ming University, No. 155, Sec. 2, Li-Nong Street, Pei-Tou, Taipei, 112 Taiwan
| | - Wei-Chih Sun
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, 386 Ta-Chung 1st Road, Kaohsiung, 81362 Taiwan
| | - Jin-Shiung Cheng
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, 386 Ta-Chung 1st Road, Kaohsiung, 81362 Taiwan
- School of Medicine, National Yang-Ming University, No. 155, Sec. 2, Li-Nong Street, Pei-Tou, Taipei, 112 Taiwan
| | - Ping-I Hsu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, 386 Ta-Chung 1st Road, Kaohsiung, 81362 Taiwan
- School of Medicine, National Yang-Ming University, No. 155, Sec. 2, Li-Nong Street, Pei-Tou, Taipei, 112 Taiwan
| | - Wei-Lun Tsai
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, 386 Ta-Chung 1st Road, Kaohsiung, 81362 Taiwan
- School of Medicine, National Yang-Ming University, No. 155, Sec. 2, Li-Nong Street, Pei-Tou, Taipei, 112 Taiwan
| | - Wen-Chi Chen
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, 386 Ta-Chung 1st Road, Kaohsiung, 81362 Taiwan
- School of Medicine, National Yang-Ming University, No. 155, Sec. 2, Li-Nong Street, Pei-Tou, Taipei, 112 Taiwan
| | - Yun-Da Li
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, 386 Ta-Chung 1st Road, Kaohsiung, 81362 Taiwan
| | - E-Ming Wang
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, 386 Ta-Chung 1st Road, Kaohsiung, 81362 Taiwan
| | - Huey-Shyan Lin
- Department of Health-Business Administration, Fooyin University, 151 Jinxue Rd, Daliao Dist, Kaohsiung City, 83102 Taiwan
| | - Hoi-Hung Chan
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, 386 Ta-Chung 1st Road, Kaohsiung, 81362 Taiwan
- School of Medicine, National Yang-Ming University, No. 155, Sec. 2, Li-Nong Street, Pei-Tou, Taipei, 112 Taiwan
- Department of Biological Sciences, National Sun Yat-sen University, 70 Lien-Hai Road, Kaohsiung, 80424 Taiwan
- Department of Business Management, National Sun Yat-sen University, 70 Lien-Hai Road, Kaohsiung, 80424 Taiwan
- College of Pharmacy and Health Care, Tajen University, 20 Weisin Road, Sin-er Village, Yanpu Township, Pingtung County 907 Taiwan
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Qiu Y, Yang Z, Li Z, Zhang W, Xue D. Is preoperative MRCP necessary for patients with gallstones? An analysis of the factors related to missed diagnosis of choledocholithiasis by preoperative ultrasound. BMC Gastroenterol 2015; 15:158. [PMID: 26577949 PMCID: PMC4650402 DOI: 10.1186/s12876-015-0392-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 11/10/2015] [Indexed: 02/07/2023] Open
Abstract
Background The diagnosis of associated choledocholithiasis prior to cholecystectomy for patients with gallstones is important for the surgical decision and treatment efficacy. However, whether ultrasound is sufficient for preoperative diagnosis of choledocholithiasis remains controversial, with different opinions on whether routine magnetic resonance cholangiopancreatography (MRCP) is needed to detect the possible presence of common bile duct (CBD) stones. Methods In this study, a total of 413 patients with gallstones who were admitted to the Department of General Surgery of the First Affiliated Hospital of Harbin Medical University in China for a period of 3 years and underwent both ultrasound and MRCP examinations were retrospectively analysed. After reviewing and screening these cases according to the literature, 11 indicators including gender, age, alanine aminotransferase, aspartate aminotransferase, total bilirubin, direct bilirubin, indirect bilirubin, alkaline phosphatase, γ-aminotransferase, CBD diameter, and concurrent acute cholecystitis were selected and comparatively analysed. Results Among the 413 patients, a total of 109 cases showed concurrent gallstones and choledocholithiasis, accounting for 26.39 % of all cases. Among them, 60 cases of choledocholithiasis were revealed by ultrasound examination, accounting for 55.05 %, while 49 cases of choledocholithiasis were not detected by ultrasound examination but were confirmed by MRCP instead (the missed diagnosis rate of ultrasound was 44.95 %). The results of statistical analysis suggested that alanine aminotransferase, acute cholecystitis, and CBD diameter were the three most relevant factors for missed diagnosis by ultrasound. Conclusion The accuracy of preoperative ultrasonography for the diagnosis of associated CBD stones for patients with gallstones is not high. However, elevated alanine aminotransferase, concurrent acute cholecystitis, and CBD diameter were identified as key factors that may affect the accuracy of the diagnosis. Thus, routine preoperative MRCP examination is suggested for patients with gallstones to rule out possible concomitant CBD stones.
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Affiliation(s)
- Yan Qiu
- Department of General Surgery, the First Affiliated Hospital of Harbin Medical University, 23 Youzheng St., Nangang Dist., 150001, Harbin, China.
| | - Zhengpeng Yang
- Department of General Surgery, the First Affiliated Hospital of Harbin Medical University, 23 Youzheng St., Nangang Dist., 150001, Harbin, China.
| | - Zhituo Li
- Department of General Surgery, the First Affiliated Hospital of Harbin Medical University, 23 Youzheng St., Nangang Dist., 150001, Harbin, China.
| | - Weihui Zhang
- Department of General Surgery, the First Affiliated Hospital of Harbin Medical University, 23 Youzheng St., Nangang Dist., 150001, Harbin, China.
| | - Dongbo Xue
- Department of General Surgery, the First Affiliated Hospital of Harbin Medical University, 23 Youzheng St., Nangang Dist., 150001, Harbin, China.
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Abstract
OBJECTIVES The aim of this study was to develop and compare the predictive accuracy of classification and regression tree (CART) analysis with logistic regression (LR) for predicting common bile duct stones (CBDS) in patients subjected to laparoscopic cholecystectomy. PATIENTS AND METHODS We prospectively collected preoperative (demographic, biochemical, ultrasonographic) and intraoperative (intraoperative cholangiography, cystic duct diameter) data for 154 patients considered for elective laparoscopic cholecystectomy at the department of General Surgery at Gornji Milanovac from 2013 through 2014. Univariate and multivariate regression analyses were used to determine independent predictors of CBDS. The CART analysis was carried out using the predictors identified by LR analysis. Various measures for the assessment of risk prediction models were determined, such as predictive ability, accuracy, the area under the receiver operating characteristic curve, and clinical utility using decision curve analysis. RESULTS The most decisive variable at the time of classification was the cystic duct diameter category, the alkaline phosphatase, and dangerous stones. The CART model was shown to have good discriminatory ability (93.9%). Accuracy was similar in both models, ranging from 92.9% in the CART model and 93.5% in the LR model. In decision curve analysis, the CART model outperformed the LR model. CONCLUSION We developed a user-friendly risk model that can successfully predict the presence of choledocholithiasis in patients planned for elective cholecystectomy. However, before recommending its use in clinical practice, a larger and more complete database should be used to further clarify the differences between models in terms of prediction of the CBDS.
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