The Performance of ASGE Criteria in Risk-Stratifying Octogenarian Patients with Suspected Choledocholithiasis in Comparison with Younger Patients

Abstract

Purpose: The American Society of Gastrointestinal Endoscopy (ASGE) guidelines for the management of choledocholithiasis propose use of 8 variables for stratifying patients with suspicion of choledocholithiasis, into low (<10%), intermediate (10-50%) and high (>50%) risk categories. We recently prospectively validated the ASGE criteria for the evaluation of suspected choledocholithiasis in all patients referred to our center. However, till date, there have been no studies to suggest if the ASGE criteria can be used effectively to risk-stratify very elderly patients with suspected choledocholithiasis. The aim of our study was to evaluate the performance of proposed ASGE criteria in risk-stratifying Octogenarian patients with suspected choledocholithiasis as compared to the younger patients. Methods: From September, 2011 to January, 2013, we evaluated 402 patients referred to our center for suspected choledocholithiasis. All the patients were categorized into high, intermediate and low risk for choledocholithiasis based on ASGE criteria. This category was not revealed to the endoscopist. We determined the presence of choledocholithiasis based on ERCP. Results: Of the 336 patients in the final analysis, 85 patients constituted the Octogenarian group and the remaining 251 constituted the younger group. Females constituted 60.5 % in the Octogenarian group and 57.6 % in the younger group. Out of 85 patients in the Octogenarian group, 66 met criteria for high risk of choledocholithiasis and 19 met criteria for intermediate risk of choledocholithiasis. Out of 251 patients in the younger group, 178 met criteria for high risk of choledocholithiasis and 73 met criteria for intermediate risk of choledocholithiasis. There were only two patients in the low risk group in the patient sample and therefore, excluded in the final analysis. Based on the eventual finding of choledocholithiasis on ERC, the high risk category based on the ASGE criteria predicted choledocholithiasis with a positive predictive value of 75.76% (95% CI 63.64-85.46%), sensitivity of 84.75% (95% CI 73.00-92.76%), and specificity of 38.46% (95% CI 20.25-59.42 %) in the octogenarian group. The high risk category predicted choledocholithiasis with a positive predictive value of 75.84% (95% CI 68.87-81.93%), sensitivity of 78.95% (95% CI 72.06-84.80%), and specificity of 46.25% (95% CI 35.03-57.76 %) in the younger group. There was no statistically significant difference between the PPV of the high risk category for the octogenarian and the younger group. Conclusion: The ASGE criteria adequately stratify Octogenarian patients at high and intermediate risk of choledocholithiasis and can be used for clinical decision making.