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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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Katzarov AK, Dunkov ZI, Popadiin I, Katzarov KS. How to measure quality in endoscopic retrograde cholangiopancreatography (ERCP). ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:265. [PMID: 30094251 DOI: 10.21037/atm.2018.05.01] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is invasive therapeutic procedure demanding specific individual approach for learning and mastering. It is associated with greater morbidity and mortality than any other procedure in gastroenterology. The risk for complications and harm for patient inevitably require strict guidelines to be followed regarding training, certification and proficiency. In an attempt to reduce the risk of complications, various endoscopic societies worldwide have established so called "Quality measures" which proved to be the back bone for safety and quality in ERCP. Recently developed ERCP quality network allowing data comparison between endoscopist is the key of reducing complications and creating a state of the art teaching program for beginner endoscopist. Further research is required regarding quality measures improvement and information exchange in the global ERCP quality network.
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Affiliation(s)
| | - Zdravko Ivanov Dunkov
- Clinic of Gastroenterology and Hepatology, Military Medical Academy, Sofia, Bulgaria
| | - Ivan Popadiin
- Clinic of Gastroenterology and Hepatology, Military Medical Academy, Sofia, Bulgaria
| | - Krum Sotirov Katzarov
- Clinic of Gastroenterology and Hepatology, Military Medical Academy, Sofia, Bulgaria
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Kang SK, Hoffman D, Ferket B, Kim MI, Braithwaite RS. Risk-stratified versus Non–Risk-stratified Diagnostic Testing for Management of Suspected Acute Biliary Obstruction: Comparative Effectiveness, Costs, and the Role of MR Cholangiopancreatography. Radiology 2017; 284:468-481. [DOI: 10.1148/radiol.2017161714] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Stella K. Kang
- From the Department of Radiology, NYU School of Medicine, 550 First Ave, New York, NY 10016 (S.K.K., D.H.); Department of Population Health, NYU Langone Medical Center, New York, NY (S.K.K., R.S.B.); Institute for Healthcare Delivery Science, Department of Population Health Science and Policy (B.F.), and Department of Medicine, Division of Gastroenterology (M.I.K.), Icahn School of Medicine at Mount Sinai, New York, NY; and Department of Medicine, NYU Medical Center, New York, NY (R.S.B.)
| | - David Hoffman
- From the Department of Radiology, NYU School of Medicine, 550 First Ave, New York, NY 10016 (S.K.K., D.H.); Department of Population Health, NYU Langone Medical Center, New York, NY (S.K.K., R.S.B.); Institute for Healthcare Delivery Science, Department of Population Health Science and Policy (B.F.), and Department of Medicine, Division of Gastroenterology (M.I.K.), Icahn School of Medicine at Mount Sinai, New York, NY; and Department of Medicine, NYU Medical Center, New York, NY (R.S.B.)
| | - Bart Ferket
- From the Department of Radiology, NYU School of Medicine, 550 First Ave, New York, NY 10016 (S.K.K., D.H.); Department of Population Health, NYU Langone Medical Center, New York, NY (S.K.K., R.S.B.); Institute for Healthcare Delivery Science, Department of Population Health Science and Policy (B.F.), and Department of Medicine, Division of Gastroenterology (M.I.K.), Icahn School of Medicine at Mount Sinai, New York, NY; and Department of Medicine, NYU Medical Center, New York, NY (R.S.B.)
| | - Michelle I. Kim
- From the Department of Radiology, NYU School of Medicine, 550 First Ave, New York, NY 10016 (S.K.K., D.H.); Department of Population Health, NYU Langone Medical Center, New York, NY (S.K.K., R.S.B.); Institute for Healthcare Delivery Science, Department of Population Health Science and Policy (B.F.), and Department of Medicine, Division of Gastroenterology (M.I.K.), Icahn School of Medicine at Mount Sinai, New York, NY; and Department of Medicine, NYU Medical Center, New York, NY (R.S.B.)
| | - R. Scott Braithwaite
- From the Department of Radiology, NYU School of Medicine, 550 First Ave, New York, NY 10016 (S.K.K., D.H.); Department of Population Health, NYU Langone Medical Center, New York, NY (S.K.K., R.S.B.); Institute for Healthcare Delivery Science, Department of Population Health Science and Policy (B.F.), and Department of Medicine, Division of Gastroenterology (M.I.K.), Icahn School of Medicine at Mount Sinai, New York, NY; and Department of Medicine, NYU Medical Center, New York, NY (R.S.B.)
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Williams E, Beckingham I, El Sayed G, Gurusamy K, Sturgess R, Webster G, Young T. Updated guideline on the management of common bile duct stones (CBDS). Gut 2017; 66:765-782. [PMID: 28122906 DOI: 10.1136/gutjnl-2016-312317] [Citation(s) in RCA: 222] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 12/08/2016] [Accepted: 12/15/2016] [Indexed: 02/06/2023]
Abstract
Common bile duct stones (CBDS) are estimated to be present in 10-20% of individuals with symptomatic gallstones. They can result in a number of health problems, including pain, jaundice, infection and acute pancreatitis. A variety of imaging modalities can be employed to identify the condition, while management of confirmed cases of CBDS may involve endoscopic retrograde cholangiopancreatography, surgery and radiological methods of stone extraction. Clinicians are therefore confronted with a number of potentially valid options to diagnose and treat individuals with suspected CBDS. The British Society of Gastroenterology first published a guideline on the management of CBDS in 2008. Since then a number of developments in management have occurred along with further systematic reviews of the available evidence. The following recommendations reflect these changes and provide updated guidance to healthcare professionals who are involved in the care of adult patients with suspected or proven CBDS. It is not a protocol and the recommendations contained within should not replace individual clinical judgement.
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Affiliation(s)
- Earl Williams
- Bournemouth Digestive Diseases Centre, Royal Bournemouth and Christchurch NHS Hospital Trust, Bournemouth, UK
| | - Ian Beckingham
- HPB Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Ghassan El Sayed
- Bournemouth Digestive Diseases Centre, Royal Bournemouth and Christchurch NHS Hospital Trust, Bournemouth, UK
| | - Kurinchi Gurusamy
- Department of Surgery, University College London Medical School, London, UK
| | - Richard Sturgess
- Aintree Digestive Diseases Unit, Aintree University Hospital Liverpool, Liverpool, UK
| | - George Webster
- Department of Hepatopancreatobiliary Medicine, University College Hospital, London, UK
| | - Tudor Young
- Department of Radiology, The Princess of Wales Hospital, Bridgend, UK
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Isherwood J, Garcea G, Williams R, Metcalfe M, Dennison AR. Serology and ultrasound for diagnosis of choledocholithiasis. Ann R Coll Surg Engl 2014; 96:224-8. [PMID: 24780789 DOI: 10.1308/003588414x13814021678033] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
INTRODUCTION Magnetic resonance cholangiopancreatography (MRCP) is not a routine investigation to exclude choledocholithiasis unless there is clinical or biochemical suspicion of common bile duct (CBD) stones. This study attempted to determine which radiological or serological parameters best predicted CBD stones. METHODS All patients undergoing MRCP from 2005 to 2011 were selected. Patients with pancreatitis were excluded. Liver function tests (LFTs) at admission and prior to MRCP were recorded, as was abdominal ultrasonography and MRCP results. Parameters measured routinely on LFTs included alkaline phosphatase (ALP), alanine transaminase (ALT) and bilirubin. Receiver operating characteristic curve area analysis (area under the curve [AUC]) and chi-squared analysis were undertaken. RESULTS Overall, 195 patients were identified, 71 of whom had CBD stones on MRCP. Raised ALP levels on admission demonstrated a correlation with CBD stones (AUC: 0.619, odds ratio [OR]: 3.16, p=0.06). At ultrasonography, a dilated CBD (OR: 3.76, p<0.001) and intrahepatic duct dilation (OR: 5.56, p<0.001) were highly significant predictors. However, only 37% of patients had a dilated CBD on ultrasonography. Ongoing elevation of LFT parameters, particularly ALP (AUC: 0.707, OR: 4.64, p<0.001) and ALT (AUC: 0.646, OR: 5.40, p<0.001), displayed a significant correlation with CBD stones. CONCLUSIONS Ongoing (even if minor) elevations of liver function test parameters should prompt the need to exclude CBD stones even in the presence of a normal CBD diameter on ultrasonography.
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Affiliation(s)
- J Isherwood
- University Hospitals of Leicester NHS Trust, UK.
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Trivedi PJ, Tse D, Al-Bakir I, D'Costa H. Appropriate patient selection in the management of common bile duct stones: when not to do ERCP. ISRN SURGERY 2012; 2012:286365. [PMID: 22779000 PMCID: PMC3384886 DOI: 10.5402/2012/286365] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2012] [Accepted: 04/20/2012] [Indexed: 12/02/2022]
Abstract
Background. Magnetic resonance cholangiopancreatography (MRCP) is noninvasive and accurate for diagnosing intra common bile duct stones (ICSs). However, given limited access, routine utilisation for investigating all patients with gallstone disease is neither practical nor cost-effective. Conversely, many individuals proceed directly to endoscopic retrograde cholangiopancreatography (ERCP), an invasive test with appreciable complications. Aim. Identify factors associated with ICS in order to improve risk-stratification for MRCP/ERCP. Methods. All patients having undergone cholecystectomy between November 2007 and October 2008 were reviewed. High-risk features for ICS were predefined, and their true presence confirmed by ERCP or intraoperative cholangiogram. Multivariate logistic regression was performed on candidate risk features. Results. Of 231 patients, 10.4% had ICS. Defining a high-risk group with "both" biochemical and ultrasound risk factors predicted ICS with 92% specificity and also bore strong association (OR 8.88). However, isolated hyperbilirubinaemia, ultrasound impression of CBD stones, and clinical risk factors did not (OR 1.10, 0.97, and 1.26). Normal liver biochemistry and normal ultrasound had a NPV of 99.5% for ICS. Conclusions. Ultrasound impression of CBD calculi without ductal dilatation is not predictive of ICS. Patients with normal liver biochemistry and normal CBD diameter on ultrasound are unlikely to have ICS and should not proceed to ERCP.
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Affiliation(s)
- Palak Jitendrakumar Trivedi
- Centre for Liver Research and NIHR Biomedical Research Unit, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
- Department of Gastroenterology, Horton General Hospital, Oxford Road, Banbury OX16 9AL, UK
| | - Donald Tse
- Department of Clinical Radiology, Horton General Hospital, Oxford Road, Banbury OX16 9AL, UK
| | - Ibrahim Al-Bakir
- Department of Surgery, Horton General Hospital, Oxford Road, Banbury OX16 9AL, UK
| | - Horace D'Costa
- Department of Clinical Radiology, Horton General Hospital, Oxford Road, Banbury OX16 9AL, UK
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Abstract
Technologic advancements have allowed imaging modalities to become more useful in the diagnosis of hepatobiliary and pancreatic disorders. Computed tomography scanners now use multidetector row technology with contrast-delayed imaging for quicker and more accurate imaging. Magnetic resonance imaging with cholangiopancreatography can more clearly delineate liver lesions and the biliary and pancreatic ducts, and can diagnose pathologic conditions early in their course. Newer technologies, such as single-operator cholangioscopy and endoscopic ultrasonography, have sometimes shown superiority to traditional modalities. This article addresses the literature regarding available imaging techniques in the diagnosis and treatment of common surgical hepatobiliary and pancreatic diseases.
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Frossard JL, Morel PM. Detection and management of bile duct stones. Gastrointest Endosc 2010; 72:808-16. [PMID: 20883860 DOI: 10.1016/j.gie.2010.06.033] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2010] [Accepted: 06/10/2010] [Indexed: 12/13/2022]
Affiliation(s)
- Jean Louis Frossard
- Gastroenterology and Digestive Surgery Service, Hôpitaux Universitaires de Genève, Université de Genève, Geneva, Switzerland
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Abstract
Endoscopic retrograde cholangiopancreatography (ERCP), once a popular modality for diagnosing biliary tract and pancreatic disease, has passed its peak utilization. In the current issue of AJG, Jamal and colleagues summarize the trends in ERCP utilization in the United States from 1988 to 2002. While ERCP utilization had increased among certain ethnic groups, its overall use has dropped considerably since 1996. In particular, they report that the use of ERCP as a diagnostic tool and in the outpatient setting has declined. The introduction of less invasive pancreaticobiliary imaging tools, namely, endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP), is likely responsible for this trend. However, ERCP is still used widely and appropriately in the therapy of pancreaticobiliary disorders. The complementary nature of alternative diagnostic tools such as EUS suggests that ERCP use will continue at its current rate, rather than fall out of favor.
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Baron TH, Petersen BT, Mergener K, Chak A, Cohen J, Deal SE, Hoffinan B, Jacobson BC, Petrini JL, Safdi MA, Faigel DO, Pike IM. Quality indicators for endoscopic retrograde cholangiopancreatography. Am J Gastroenterol 2006; 101:892-7. [PMID: 16635233 DOI: 10.1111/j.1572-0241.2006.00675.x] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Baron TH, Petersen BT, Mergener K, Chak A, Cohen J, Deal SE, Hoffman B, Jacobson BC, Petrini JL, Safdi MA, Faigel DO, Pike IM. Quality indicators for endoscopic retrograde cholangiopancreatography. Gastrointest Endosc 2006; 63:S29-34. [PMID: 16564909 DOI: 10.1016/j.gie.2006.02.019] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Todd H Baron
- ASGE Communications Department, 1520 Kensington Road, Suite 202, Oak Brook, IL 60523, USA.
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Literature Watch. J Laparoendosc Adv Surg Tech A 2005. [DOI: 10.1089/lap.2005.15.98] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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