Accuracy of ASGE criteria for the prediction of choledocholithiasis

Abstract

Background/aims: Few studies have validated the performance of guidelines for the prediction of choledocholithiasis (CL). Our objective was to prospectively assess the accuracy of the American Society for Gastrointestinal Endoscopy (ASGE) guidelines for the identification of CL.Methods: A two-year prospective evaluation of patients with suspected CL was performed. We evaluated the ASGE guidelines and its component variables in predicting CL.Results: A total of 256 patients with suspected CL were analyzed. Of the 208 patients with high-probability criteria for CL, 124 (59.6%) were found to have a stone/sludge at endoscopic retrograde cholangiopancreatography (ERCP). Among 48 patients with intermediate-probability criteria, 21 (43.8%) had a stone/ sludge. The performance of ASGE high-and intermediate-probability criteria in our population had an accuracy of 59.0% (85.5% sensitivity, 24.3% specificity) and 41.0% (14.4% sensitivity, 75.6% specificity), respectively. The mean ERCP delay time was 6.1 days in the CL group and 6.4 days in the group without CL, p = 0.638. The presence of a common bile duct (CBD) > 6 mm (OR 2.21; 95% CI, 1.20-4.10), ascending cholangitis (OR 2.37; 95% CI, 1.01-5.55) and a CBD stone visualized on transabdominal US (OR 3.33; 95% CI, 1.48-7.52) were stronger predictors of CL. The occurrence of biliary pancreatitis was a strong protective factor for the presence of a retained CBD stone (OR 0.30; 95% CI,.Conclusions: Irrespective of a patient's ASGE probability for CL, the application of current guidelines in our population led to unnecessary performance of ERCPs in nearly half of cases.

Once upon a Time a Guideline Was Used for the Evaluation of Suspected Choledocholithiasis: A Fairy Tale or a Nightmare

“…The overall accuracy of the guidelines was, in this study, 62.1% (47.4% sensitivity and 73% specificity). In Spain, a prospective study analyzed 256 patients with suspected choledocholithiasis [3] . Of the 208 patients with high-risk probability criteria for CBD stones, 124 (59.6%) patients were found to have a stone/sludge on ERCP, providing an overall accuracy of 59.0% (85.5% sensitivity and 24.3% specificity).…”

“…I remember that patients at high risk were defined as having a probability of choledocholithiasis >50%. Published series reported that patients with high-risk criteria for CBD stones had a documented stone/sludge in a range between 40 and 79.8% (average 60.1%) of the ERCPs [2,3,5,[14][15][16] . The majority of the published series concluded that the ASGE criteria demonstrated a probability of >50% of the patients having CBD stones.…”

“…The majority of the published series concluded that the ASGE criteria demonstrated a probability of >50% of the patients having CBD stones. However, authors should also consider that the ASGE guidelines performed suboptimally, and the application of the current guidelines would lead to unnecessary diagnostic ERCPs in more than one-third of the patients, which is not acceptable [2,3,5,[14][15][16] .…”

“…He et al [5] suggest that a revised algorithm with more stringent criteria that includes choledocholithiasis on abdominal US and/or bilirubin levels >4 mg/dL plus CBD dilation on abdominal US may improve patient selection and reduce the risk of diagnostic ERCP. However, in the clinical scenario, most of the authors [3,5,[14][15][16] , including myself, advocate the use of alternative diagnostic strategies for all patients with high and intermediate probability of choledocholithiasis, namely MRCP or EUS before ERCP. The ASGE guidelines should be used carefully because they are not a fairy tale for sure, and a lifethreatening complication of a diagnostic ERCP is always a nightmare.…”

Accuracy of ASGE criteria for the prediction of choledocholithiasis

“…I read with interest the article "Accuracy of ASGE criteria for the prediction of choledocholithiasis" by Nárvaez et al (1). Patients with suspicion of choledocholithiasis (CL) were categorized according to the American Society for Gastrointestinal Endoscopy (ASGE) recommendations.…”