Accuracy of New 2019 ASGE Criteria for the Prediction of Choledocholithiasis. Validation Study on Patients with Symptomatic Cholelithiasis

Abstract

Introduction: The American Society for Gastrointestinal Endoscopy (ASGE) published guidelines in 2019 for the prediction of choledocholithiasis, to identify patients with the highest probability of benefiting from endoscopic retrograde cholangiopancreatography (ERCP). Based on clinical, radiological and biochemical predictors, patients are classified in low, intermediate and high risk, in order to guide the therapeutical management. Primary objective is to perform a validation study of ASGE criteria in our population. Methods: Retrospective observational study of 176 patients with symptomatic cholelithiasis (acute cholecystitis, obstructive jaundice, acute pancreatitis or cholangitis) between January and October 2017. Choledocholithiasis was defined as the presence of CBD stones or sludge on endoscopic ultrasound, magnetic resonance cholangiopancreatography (MRCP), ERCP or cholangiography. Non-choledocholithiasis was defined as negative ERCP, cholangiography or asymptomatic patients 6 weeks after cholecystectomy. Patients were classified in low, intermediate or high risk based on 2019 ASGE scales (Fig.1). Using SPSS, a validation study was performed. Results: 176 patients were classified in the following risk groups: high (26,1%), intermediate (64,8%) and low (9,1%). 26,1% (46/176) of the patients met high risk criteria, meaning that almost a third would be initially managed with ERCP, of which 69,6% presented with choledocholitiasis (Fig 1). Only 9,6% of the patients with intermediate risk had choledocholithiasis, and none on the low risk group (p<0,001). The accuracy of 2019-ASGE criteria in our population is 80,68%, with an 86,92% specificity and a 86,92% NPV. Both CBD stone on ultrasound and cholangitis were good predictors, with a specificity of 94,62% and 95,38% respectively, and a +LR of 8,08 and 5,18 respectively. Abnormal biochemical test was the predictor with the highest sensitivity (93,48%). Validations test’s results are shown on Table 1. Multivariable logistic regression analysis revealed that BD stones on ultrasound (OR 8,79; 95%IC 2,66-29,06; p<0,001) and abnormal biochemical tests (OR 4,18; 95%IC 1,15-15,22; p=0,03) were independently associated with the presence of a stone. Cholangitis was close to significance (OR 3,08; 95%IC 0,91-10,48; p=0,072).FP03.02AccuracySensitivitySpecificityPPVNPV+LR-LR2019 ASGE Criteria80,68%63,04%86,92%63,04%86,92%4,820,43High riskCBD stone81,25%43,48%94,62%74,07%82,55%8,080,60Cholangitis76,70%23,91%95,38%64,71%77,99%5,180,80Total bilirubin >4 mg/dl and dilated CBD76,70%30,43%82,55%66,67%79,35%1,740,84Intermediate riskAbnormal biochemical tests50,00%93,48%34,38%33,86%93,62%1,420,19Age >55 years46,02%18,96%36,15%29,06%79,66%0,302,24Dilated CBD72,73%52,17%80,00%48,00%82,54%2,610,60 Open table in a new tab Conclusion: 2019-ASGE criteria might be useful in order to guide the correct management of choledocholithiasis, avoiding the performance of initial ECPR on patients with intermediate or low risk of choledocholithiasis. CBD stones on ultrasound and abnormal biochemical tests were independently associated with the presence of a choledocholithiasis.