Suspected common bile duct stones: reduction of unnecessary ERCP by pre-procedural imaging and timing of ERCP

Abstract

Background Endoscopic retrograde cholangiopancreatography (ERCP) is the procedure of choice to remove sludge/stones from the common bile duct (CBD). In a small but clinically important proportion of patients with suspected choledocholithiasis ERCP is negative. This is undesirable because of ERCP associated morbidity. We aimed to map the diagnostic pathway leading up to ERCP and evaluate ERCP outcome. Methods We established a prospective multicenter cohort of patients with suspected CBD stones. We assessed the determinants that were associated with CBD sludge or stone detection upon ERCP. Results We established a cohort of 707 patients with suspected CBD sludge or stones (62% female, median age 59 years). ERCP was negative for CBD sludge or stones in 155 patients (22%). Patients with positive ERCPs frequently had pre-procedural endoscopic ultrasonography (EUS) or magnetic resonance cholangiopancreatography (MRCP) imaging (44% vs. 35%; P = 0.045). The likelihood of ERCP sludge and stones detection was higher when the time interval between EUS or MRCP and ERCP was less than 2 days (odds ratio 2.35; 95% CI 1.25–4.44; P = 0.008; number needed to harm 7.7). Conclusions Even in the current era of society guidelines and use of advanced imaging CBD sludge or stones are absent in one out of five ERCPs performed for suspected CBD stones. The proportion of unnecessary ERCPs is lower in case of pre-procedural EUS or MRCP. A shorter time interval between EUS or MRCP increases the yield of ERCP for suspected CBD stones and should, therefore, preferably be performed within 2 days before ERCP. Graphical abstract

Magnetic Resonance Cholangiopancreatography: Diagnostic Role in Evaluating Pancreaticobiliary Abnormalities

“…The variation in the MRCP results of diagnosing the CBD stones compared to the ERCP can be attributed to the variation in the MRCP protocol itself. One more explanation was mentioned by Christina et al, 2023 (15) who stated that when additional pre-ERCP imaging was performed (EUS/MRCP), the chance of CBD sludge or stones during ERCP increased. Timing is of importance, and it was revealed that a delay of more than two days between diagnostic imaging (EUS/ MRCP) and ERCP reduces the chance of a positive ERCP.…”

“One-day, one-stay, and one-step” lessons from the Danish guidelines for the treatment of gallstone disease

“…However, recent work has shown that when performing ERCP in patients fulfilling these criteria, you may perform ERCP in a significant proportion of patients without bile duct stones. In some, because stones passed spontaneously, in some because there was an alternative diagnosis ( 15 ). As always, a hurdle to optimal patient care is the sensitivity and specificity of our current diagnostic criteria, as stated by the guideline authors in their introduction.…”

Rendimiento diagnóstico de la endosonografía biliopancreática en pacientes con riesgo intermedio de coledocolitiasis

“…Se calcula que la sensibilidad de la ESBP es del 97% (IC 95%: 91-99) mientras que su especificidad es del 90% (IC 95%: 83-94), comparado con la CRM con una sensibilidad del 87% (IC 95%: 80-93) y especificidad del 92% (IC 95%: 87-96) (6) con respecto al diagnóstico de coledocolitiasis. De igual manera, el uso de la ESBP sirve como herramienta para disminuir el número de CPRE innecesarias gracias a su alto valor predictivo negativo (VPN) considerando las complicaciones asociadas a esta (7)(8)(9)(10)(11) . En el estudio publicado por Patel et al, la ESBP como primera aproximación diagnóstica evitó la realización de CPRE en un 57,7% de los pacientes (12) .…”