Parameters Suggesting Spontaneous Passage of Stones from Common Bile Duct: A Retrospective Study

Invalidity of Tokyo guidelines in acute biliary pancreatitis: A multicenter cohort analysis of 944 pancreatitis cases

BACKGROUND

There is a noteworthy overlap between the clinical picture of biliary acute pancreatitis (AP) and the 2018 Tokyo guidelines currently used for the diagnosis of cholangitis (AC) and cholecystitis (CC). This can lead to significant antibiotic and endoscopic retrograde cholangiopancreatography (ERCP) overuse.

OBJECTIVES

We aimed to assess the on-admission prevalence of AC/CC according to the 2018 Tokyo guidelines (TG18) in a cohort of biliary AP patients, and its association with antibiotic use, ERCP and clinically relevant endpoints.

METHODS

We conducted a secondary analysis of the Hungarian Pancreatic Study Group's prospective multicenter registry of 2195 AP cases. We grouped and compared biliary cases (n = 944) based on the on-admission fulfillment of definite AC/CC according to TG18. Aside from antibiotic use, we evaluated mortality, AC/CC/AP severity, ERCP performance and length of hospitalization. We also conducted a literature review discussing each criteria of the TG18 in the context of AP.

RESULTS

27.8% of biliary AP cases fulfilled TG18 for both AC and CC, 22.5% for CC only and 20.8% for AC only. Antibiotic use was high (77.4%). About 2/3 of the AC/CC cases were mild, around 10% severe. Mortality was below 1% in mild and moderate AC/CC patients, but considerably higher in severe cases (12.8% and 21.2% in AC and CC). ERCP was performed in 89.3% of AC cases, common bile duct stones were found in 41.1%.

CONCLUSION

Around 70% of biliary AP patients fulfilled the TG18 for AC/CC, associated with a high rate of antibiotic use. Mortality in presumed mild or moderate AC/CC is low. Each of the laboratory and clinical criteria are commonly fulfilled in biliary AP, single imaging findings are also unspecific-AP specific diagnostic criteria are needed, as the prevalence of AC/CC are likely greatly overestimated. Randomized trials testing antibiotic use are also warranted.

Factors related to the spontaneous passage of common bile duct stones through the papilla: a single-center retrospective cohort study

OBJECTIVE

Common bile duct (CBD) stones can spontaneously pass through the papilla. This study explored factors associated with stone passage by comparing differences in the clinical features of stones retained in the CBD and excreted stones.

METHODS

Data were retrospectively collected for all patients who were hospitalized in our center between March 2016 and May 2021 with clinical, laboratory, or imaging evidence of CBD stones. All patients underwent endoscopic retrograde cholangiopancreatography (ERCP) and were classified into two groups: group A (stones extracted by ERCP, n = 86) and group B (stones discharged before ERCP, n = 15). Demographic data, biochemical and radiological findings were compared between the groups.

RESULTS

Stone size (0.82 vs. 0.33 cm), and levels of total bilirubin (58.2 vs. 28.8 μmol/L), gamma-glutamyl transpeptidase (416.7 vs. 193.9 U/L), alkaline phosphatase (191.9 vs. 123.1 U/L), carbohydrate antigen 19-9 (603.7 vs. 37.2 U/mL), and α-L-fucosidase (37.4 vs. 22.6 U/L) were significantly higher in group A than in group B. Logistic regression analyses showed that stone size was the only factor significantly associated with spontaneous passage of CBD stones.

CONCLUSIONS

CBD stones less than 0.33 cm in size may be self-expelled through the papilla.

Safety, quality and efficiency of intra-operative imaging for treatment decisions in patients with suspected choledocholithiasis without pre-operative magnetic resonance cholangiopancreatography

INTRODUCTION

Cholecystectomy is the accepted treatment for patients with symptomatic gallstones. In this study, we evaluate a simplified strategy for managing suspected synchronous choledocholithiasis by focussing on intra-operative imaging as the primary decision-making tool to target common bile duct (CBD) stone treatment.

METHODS

All elective and emergency patients undergoing laparoscopic cholecystectomy (LC) for gallstones with any markers of synchronous choledocholithiasis were included. Patients unfit for surgery or who had pre-operative proof of choledocholithiasis were excluded. Intra-operative imaging was used for evaluation of the CBD. CBD stone treatment was with bile duct exploration (LCBDE) or endoscopic retrograde cholangiopancreatography (LC + ERCP). Outcomes were safety, effectiveness and efficiency.

RESULTS

506 patients were included. 371 (73%) had laparoscopic ultrasound (LUS), 80 (16%) had on-table cholangiography (OTC) and 55 (11%) had both. 164 (32.4%) were found to have CBD stones. There was no increase in length of surgery for LC + LUS compared with average time for LC only in our unit (p = 0.17). 332 patients (65.6%) had clear ducts. Imaging was indeterminate in 10 (2%) patients. Overall morbidity was 10.5%. There was no mortality. 142 (86.6%) patients with stones on intra-operative imaging proceeded to LCBDE. 22 (13.4%) patients had ERCP. Sensitivity and specificity of intra-operative imaging were 93.3 and 99.1%, respectively. Success rate of LCBDE was 95.8%. Effectiveness was 97.8%.

CONCLUSIONS

Eliminating pre-operative bile duct imaging in favour of intra-operative imaging is safe and effective. When combined with intra-operative stone treatment, this method becomes a true 'single-stage' approach to managing suspected choledocholithiasis.

Serum Amylase Levels is a Predictor for Negative Endoscopic Retrograde Cholangiopancreatography for Suspected Common Bile Duct Stones

Negative endoscopic retrograde cholangiopancreatography (ERCP) for suspected common bile duct stones (CBDS) may be associated with significant morbidity and should be avoided. Between 2010 and 2018, 85 patients who have undergone negative ERCP for suspected CBDS were retrospectively evaluated and compared with 318 patients with positive findings. Predictors for negative ERCP were assessed. Patients with negative ERCP were younger; had increased levels of serum amylase, alanine transaminase, and lactate dehydrogenase; and increased hemoglobin. Even though preprocedure computed tomography (CT) or ultrasonography demonstrating CBDS were highly predictive of positive findings on ERCP, of the 212 patients with CBDS on computed tomography or ultrasonography, 17 (8%) eventually had a negative ERCP, suggesting spontaneous stone passage. An increased serum amylase level was the only predictor for negative ERCP in multivariate analysis, including in patients with preprocedure CBDS on imaging. The data suggest that assessing serum amylase may assist in avoiding unnecessary examinations.

A rolling stone: vomiting of a gallstone without the presence of a biliary-enteric fistula

Gallstones may pass into the gastrointestinal tract spontaneously through the ampulla of Vater or through a biliary-enteric fistula. This report describes an extremely rare case of a patient vomiting a gallstone without the presence of a fistula between the gallbladder and the gastrointestinal tract. Furthermore, no imaging findings of gallstones disease appeared. The patient has been treated conservatively and all symptoms subsided. The patient remains asymptomatic 3 months after treatment and an elective laparoscopic cholecystectomy was arranged. Including this reported case, only three cases have been described in the literature worldwide. However, our case is the only one characterized by retrograde flow of the gallstones into the stomach without symptoms of bowel obstruction or other underlying pathologies.

The influence of stone size on spontaneous passage of common bile duct stones in patients with acute cholangitis: A retrospective cohort study

Background

The common bile duct (CBD) stones passage in patients with cholangitis was unclear.

This study aimed to evaluate the effect on CBD stone sizes and predicting factors on spontaneous passage in patients with cholangitis.

Method

The medical records of cholangitis at Her Royal Highness Princess Maha Chakri Sirindhorn Medical Center, Srinakharinwirot University from January 2014 to December 2019 were retrospectively reviewed. Patients with acute cholangitis from CBD stones underwent ERCP in the same admission were enrolled.

Result

Of the 96 patients, The rate of spontaneous passage of CBD stones was 19.8%. By univariate analysis, factors significantly associated with a predictor of spontaneous CBD stone passage in patient with cholangitis were single CBD stone (p = 0.001), CBD stone diameter < 5 mm (p < 0.001), and clinical symptom improved before ERCP procedure (p = 0.004). Multivariate logistic regression analyses also revealed that these three factors were significantly associated with spontaneous passage. From ROC curve analysis, stone size of less than 4.85 mm was more likely to pass spontaneously with acceptable sensitivity (81.8%) and specificity (78.9%).

Conclusions

CBD stone diameter < 5 mm, single CBD stone and improved clinical symptom before ERCP procedure are key predictors of spontaneous CBD stone passage in cholangitis.

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The rate of spontaneous passage of CBD stones in cholangitis was 19.8%.

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Stone size < 5 mm, single stone and improved clinical symptom before ERCP are predictors of spontaneous passage.

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Stone size < 4.85 mm was more likely to pass spontaneously with sensitivity (81.8%) and specificity (78.9%).