BACKGROUND Existing guidelines aim to stratify the likelihood of choledocholithiasis in order to guide the use of ERCP versus a lower risk diagnostic study such as EUS, magnetic resonance cholangiopancreatography (MRCP), or intraoperative cholangiography. OBJECTIVE To assess the performance of existing guidelines in predicting choledocholithiasis and to determine if trends in laboratory parameters improve diagnostic accuracy. DESIGN Retrospective cohort study. SETTING Tertiary-care hospital. PATIENTS Hospitalized patients presenting with suspected choledocholithiasis over a 6 year period. INTERVENTIONS Assessment of the American Society for Gastrointestinal Endoscopy (ASGE) guidelines, its component variables, and laboratory trends in predicting choledocholithiasis. MAIN OUTCOME MEASUREMENTS The presence of choledocholithiasis confirmed by EUS, MRCP, or ERCP. RESULTS One hundred seventy-nine (35.9%) of the 498 eligible patients met ASGE high-probability criteria for choledocholithiasis on initial presentation. Of those, 99 subjects (56.3%) had stone/sludge on subsequent confirmatory test. Among cases not meeting high-probability criteria on presentation, 111 (34.8%) had a stone/sludge. The overall accuracy of the guidelines in detecting choledocholithiasis was 62.1% (47.4% sensitivity, 73% specificity) based upon data available at presentation. The accuracy was unchanged when incorporating the second set of liver chemistries obtained after admission (63.2%), suggesting that laboratory trends did not improve performance. LIMITATIONS retrospective study; inconsistent timing of second set of biochemical markers. CONCLUSION In our cohort of patients, existing choledocholithiasis guidelines lacked diagnostic accuracy, likely resulting in overuse of ERCP. Incorporation of laboratory trends did not improve performance. Additional research focused on risk stratification is necessary toward the goal of eliminating unnecessary diagnostic ERCP.

No abstract

No abstract

No abstract

This document was reviewed and approved by the Governing Board of the American Society for Gastrointestinal Endoscopy This is one of a series of documents prepared by the American Society for Gastrointestinal Endoscopy (ASGE) Training Committee. This curriculum document contains recommendations for training and is intended for use by endoscopy training directors, endoscopists involved in teaching endoscopy, and trainees in endoscopy. It was developed as an overview of techniques currently favored for the performance and training in endoscopic retrograde cholangiopancreatography (ERCP) and to serve as a guide to published references, videos, and other resources available to the trainer. By providing information to endoscopy trainers about the common practices used by experts in performing the technical aspects of the procedure, the ASGE hopes to improve the teaching and performance of ERCP.