Predictors Of Common Bile Duct Stones Research Articles

Combination of CT findings can reliably predict radiolucent common bile duct stones: a novel approach using a CT-based nomogram.

To identify CT features that reliably predict the presence of radiolucent common bile duct (CBD) stones. This retrospective study included 112 patients (mean age, 60.6years) with clinically suspected CBD stones that were not visible on CT. All patients had undergone CT followed by endoscopic retrograde cholangiopancreatography (ERCP) to confirm the presence (n = 66) or absence (n = 46) of CBD stones. Two radiologists independently evaluated the CT images. Univariable and multivariable logistic regression analyses were performed to identify demographic, laboratory, and CT predictors for CBD stones. We developed a nomogram based on these results and assessed its performance. In the multivariate analysis, CBD diameter ≥ 8mm (odds ratio [OR], 10.12; p < 0.001), pericholecystic fat infiltration (OR, 3.76, p = 0.014), and papillitis (OR, 2.85; p < 0.049) were independent CT predictors of CBD stones. Combination of all three features had a specificity of 100%. Of these features, CBD diameter ≥ 8mm was the best single predictor. The CT-based nomogram had an area under the curve (AUC) of 0.847 (95% confidence interval [CI], 0.777-0.916) and an accuracy of 77.7% (95% CI, 69.1-84.4%). The combination of significant CT features (CBD diameter ≥ 8mm, pericholecystic fat infiltration, and papillitis) translated into a nomogram allows a reliable estimation of CBD stone presence. It may serve as a decision support tool to determine whether to proceed to further diagnostic tests or treatment option. • CBD diameter ≥ 8mm (odds ratio [OR] = 10.12, p < 0.001), pericholecystic fat infiltration (OR = 3.76, p = 0.014), and papillitis (OR = 2.85, p = 0.049) were independent predictors of radiolucent CBD stones. • A CBD diameter ≥ 8mm was the best predictor of CBD stones. • A nomogram based on a combination of these three CT signs predicted the presence of CBD stones and helped classify patients that should go immediately to ERCP, those who require a further investigation, and those who can safely be managed conservatively.

Predictors of persistent common bile duct stones in mild acute biliary pancreatitis; the role of liver enzyme and dilated CBD on ultrasound

Background: Abnormal liver enzyme tests (LET) are frequent in acute biliary pancreatitis (ABP), and not always related to persistent common bile duct stones (CBDS). The aim of our study was to determine whether LET on admission, value variations at 24 h and dilated common bile duct (CBD) on ultrasound (US) are appropriate predictors of CBDS in mild ABP. Methods: Data were analysed from our prospective database of 56 consecutive patients diagnosed of mild ABP; of whom 14(25%) had persistent CBDS confirmed by endoscopic retrograde cholangio-pancreatography. LET; alanin aminotransferase (ALT), aspartate aminotransferase (AST) and total bilirubin (TB) on admission and at 24 h were evaluated. Higher LET values were considered: TB>1.2mg/dl, AST>75U/l, ALT>75U/l. Abdominal US was performed. Predictive accuracy of the variables was measured using area-under-the-receiver-operating characteristic curve (AUC) analysis. Results: Neither abnormal LET on admission or its raised values at 24h showed accuracy in predicting CBDS (AUC values under 0.5), nor did the association of the 3 abnormal LET (AUC=0.66; 0.51-0.82). However, dilated CBD on US showed good accuracy for predicting CBDS (AUC=0.75; 0.58-0.91). Conclusion: A dilated CBD on US seems to be superior than abnormal LET in predicting CBDS in mild ABP, it could help to guide decisions making in the emergency setting of mild ABP, on selection of patients who will benefit from other specific imaging techniques.

Predictors of persistent common bile duct stones in mild acute biliary pancreatitis; the role of liver enzyme and dilated CBD on ultrasound

Background: Abnormal liver enzyme tests (LET) are frequent in acute biliary pancreatitis (ABP), and not always related to persistent common bile duct stones (CBDS). The aim of our study was to determine whether LET on admission, value variations at 24 h and dilated common bile duct (CBD) on ultrasound (US) are appropriate predictors of CBDS in mild ABP. Methods: Data were analysed from our prospective database of 56 consecutive patients diagnosed of mild ABP; of whom 14(25%) had persistent CBDS confirmed by endoscopic retrograde cholangio-pancreatography. LET; alanin aminotransferase (ALT), aspartate aminotransferase (AST) and total bilirubin (TB) on admission and at 24 h were evaluated. Higher LET values were considered: TB>1.2mg/dl, AST>75U/l, ALT>75U/l. Abdominal US was performed. Predictive accuracy of the variables was measured using area-under-the-receiver-operating characteristic curve (AUC) analysis. Results: Neither abnormal LET on admission or its raised values at 24h showed accuracy in predicting CBDS (AUC values under 0.5), nor did the association of the 3 abnormal LET (AUC=0.66; 0.51-0.82). However, dilated CBD on US showed good accuracy for predicting CBDS (AUC=0.75; 0.58-0.91). Conclusion: A dilated CBD on US seems to be superior than abnormal LET in predicting CBDS in mild ABP, it could help to guide decisions making in the emergency setting of mild ABP, on selection of patients who will benefit from other specific imaging techniques.

Selective Endoscopic Cholangiography for the Detection of Common Bile Duct Stones in Patients with Cholelithiasis

The detection and management of common bile duct (CBD) stones in patients undergoing laparoscopic cholecystectomy continues to be controversial. Several diagnostic and therapeutic strategies have been suggested. These include intraoperative cholangiography, selective endoscopic retrograde cholangiopancreatography (ERCP), magnetic resonance cholangiopancreatography, and endoscopic ultrasonography. The aim of this study was to evaluate the efficacy of selective ERCP in detecting CBD stones in patients with cholelithiasis before laparoscopic cholecystectomy. In a prospective study, patients with cholelithiasis who presented during a 6-year period were assessed on a selective basis with ERCP for suspected CBD stones before laparoscopic cholecystectomy. ERCP was carried out if the patient had any of the following criteria: a dilated CBD on ultrasound, gallstone pancreatitis, or abnormal liver function tests. Intraoperative cholangiography was not performed in any of the patients. Long-term follow-up was undertaken. The study included 427 patients. On the basis of selective criteria, ERCP was carried out in 41 patients (9.6 %), with confirmed CBD stones in 22 cases (53.7 %). The most useful predictor of CBD stones on ERCP was the presence of a dilated CBD in association with abnormal liver function tests. In this situation, CBD stones were identified in 14 of 17 cases (82 %). Abnormal liver function tests alone had a sensitivity of 50 % (four of eight). All other parameters used in isolation had a lower detection rate. During a median follow-up period of 6 years (range 1-10 years), six of 386 patients (1.6 %) with initially normal imaging and biochemical tests presented again with retained stones. All were successfully managed by ERCP and sphincterotomy. There were no major complications. Preoperative selective ERCP is effective in detecting clinically significant CBD stones. However, there is a high false-negative rate when a single criterion is used to guide therapy. Multivariate analysis of preoperative parameters for risk stratification, in conjunction with other imaging modalities, may make it possible to minimize unnecessary ERCPs.

Selective use of preoperative endoscopic retrograde cholangiopancreatography in the era of laparoscopic cholecystectomy.

The use of endoscopic retrograde cholangiopancreatography (ERCP) in the management of suspected common bile duct (CBD) stones prior to laparoscopic cholecystectomy is common. The associated morbidity can be significant. The present study determines significant predictors of CBD stones and improves the selection of patients for preoperative ERCP. All preoperative ERCP for suspected CBD stones in the year 1998 were studied retrospectively. Univariate and multivariate analyses of a number of clinical, biochemical and radiological variables were carried out to determine the best predictors of CBD stones. A total of 112 patients had successful preoperative ERCP. Sixty-one per cent of these were negative for stones and the morbidity was 9%. Univariate analysis revealed the following variables as predictors: cholangitis (P = 0.006), abnormal serum bilirubin > or = 3 days (P = 0.002), serum alkaline phosphatase > or = 130 U/L (P = 0.002), deranged liver function tests (P = < 0.001) and CBD diameter > or = 8 mm (P = 0.009) with positive predictive values of 80%, 68%, 49%, 38% and 52%, respectively. Multivariate analysis revealed the model with the best ability to discriminate for CBD stones (P = 0.0005) was cholangitis, abnormal serum bilirubin for > or = 3 days and CBD diameter > or = 8 mm. The best predictors from this study had a sensitivity of 80% and a specificity of 27%. The predictors of CBD stones are imprecise. Until laparoscopic exploration of CBD becomes widely available, ERCP prior to cholecystectomy will remain popular. The use of stricter selection criteria can reduce the number of negative preoperative ERCP.

Prediction of common bile duct stones by noninvasive tests.

To define accurate and useful predictors of common bile duct stones (CBDS). The ability to predict CBDS with noninvasive tests can avoid unnecessary, costly, or risky procedures. All patients referred for examination for CBDS by endoscopic ultrasonography (EUS) from 1993-1996 were prospectively entered in a database. In a first sample selected randomly from the whole population, predictors of CBDS were determined by univariate analysis and logistic regression. Predictors were subsequently tested in that sample and in the rest of the population. A separate analysis was done for patients planned for cholecystectomy. Eight hundred and eighty patients (328 men, 552 women), aged 57.8 +/- 17 years (range 16-94), were included. The prevalence of CBDS was 18.8%. Age, serum levels of bilirubin, aspartate aminotransferase, alanine aminotransferase, gamma-glutamyl transferase (GGT), and alkaline phosphatase, and the existence of jaundice and fever, a dilated bile duct, and a pathologic gallbladder were found to be associated with CBDS. Logistic regression was undertaken separately for patients younger than 70 years (predictors: GGT >7 x normal; pathologic gallbladder; dilated bile duct) and older than 70 years (predictors: GGT >7 x normal; fever > 38 degrees C; dilated bile duct). Odds ratios were 3 to 6.7. The model was satisfactorily applicable to the second sample; age <70 years: chi2 = 3.3 (NS); age >70 years: chi2 = 3.8 (NS). In patients younger than age 70 and planned for cholecystectomy, the combination of the level of GGT and dilated bile duct predicted CBDS accurately. A simple screening of patients at risk for CBDS can be achieved with three predictive criteria adapted for the patient's age.

Gallstone pancreatitis: a prospective study on the incidence of cholangitis and clinical predictors of retained common bile duct stones.

The aim of this study was to define the incidence of cholangitis in gallstone pancreatitis, in the absence of cholangitis, to identify the clinical predictors of persistent common bile duct (CBD) stones at endoscopic retrograde cholangiography (ERCP) or at intraoperative cholangiography (IOC). A total of 122 consecutive patients with acute gallstone pancreatitis were prospectively evaluated for the presence of CBD stones as determined by elective ERCP or IOC. Urgent ERCP was restricted to patients with concomitant cholangitis. APACHE II scores and serial laboratory data were obtained. Four (3%) patients had cholangitis and all underwent urgent ERCP successfully. Eighteen (15%) patients without cholangiogram were excluded. The remaining 100 patients underwent elective ERCP or IOC on a mean of hospital day 6.8. Twenty-one (21%) patients had persistent CBD stones. Univariate analysis detected significant differences in serum total bilirubin, ALT, and alkaline phosphatase levels between patients with and without persistent CBD stones. On multivariate analysis, serum total bilirubin on hospital day 2 was the best predictor of CBD stones. A serum total bilirubin level > 1.35 mg/dl had a sensitivity of 90.5% and specificity of 63%. Age, gender, mean APACHE II score, amylase, and presence of CBD dilation on ultrasound were not predictive of CBD stones. In patients with gallstone pancreatitis, 1) cholangitis is uncommon, and 2) the best clinical predictor of persistent CBD stones is serum total bilirubin on hospital day 2.

Gallstone Pancreatitis: A Prospective Study on the Incidence of Cholangitis and Clinical Predictors of Retained Common Bile Duct Stones

Objective: The aim of this study was to define the incidence of cholangitis in gallstone pancreatitis, in the absence of cholangitis, to identify the clinical predictors of persistent common bile duct (CBD) stones at endoscopic retrograde cholangiography (ERCP) or at intraoperative cholangiography (IOC). Methods: A total of 122 consecutive patients with acute gallstone pancreatitis were prospectively evaluated for the presence of CBD stones as determined by elective ERCP or IOC. Urgent ERCP was restricted to patients with concomitant cholangitis. APACHE II scores and serial laboratory data were obtained. Results: Four (3%) patients had cholangitis and all underwent urgent ERCP successfully. Eighteen (15%) patients without cholangiogram were excluded. The remaining 100 patients underwent elective ERCP or IOC on a mean of hospital day 6.8. Twenty-one (21%) patients had persistent CBD stones. Univariate analysis detected significant differences in serum total bilirubin, ALT, and alkaline phosphatase levels between patients with and without persistent CBD stones. On multivariate analysis, serum total bilirubin on hospital day 2 was the best predictor of CBD stones. A serum total bilirubin level > 1.35 mg/dl had a sensitivity of 90.5% and specificity of 63%. Age, gender, mean APACHE II score, amylase, and presence of CBD dilation on ultrasound were not predictive of CBD stones. Conclusion: In patients with gallstone pancreatitis, 1) cholangitis is uncommon, and 2) the best clinical predictor of persistent CBD stones is serum total bilirubin on hospital day 2.

ROUTINE USE OF ULTRASOUND 24 HOURS BEFORE LAPAROSCOPIC CHOLECYSTECTOMY CAN PREDICT THE NEED FOR INTRAOPERATIVE CHOLANGIOGRAM: RESULTS OF A 12‐MONTH PROSPECTIVE AUDIT

SUMMARYIntraoperative cholangiograms and exploration of the common bile duct (CBD) during laparoscopic cholecystectomy are technically more demanding than during open cholecystectomy. This has led to many surgeons using a selective policy for cholangiography. In this study we prospectively assessed whether biliary ultrasound (CBD diameter ≥6 mm) or one or more abnormal liver function tests (LFTs) performed in the 24 hours preoperatively could predict the need for cholangiography. Forty‐five patients were studied (14 male, 31 female), mean age 47.8 years. All patients with one or both tests abnormal preoperatively (19 patients) underwent intraoperative cholangiograms. Seven CBD stones were identified (16%). There was no evidence of CBD stones in patients not undergoing cholangiography at a median follow‐up of 18 months. In patients with stones, three underwent open CBD exploration, and four underwent endoscopic retrograde choledochopancreatography (ERCP) and sphincterotomy in the early postoperative period without complications. CBD diameter ≥6 mm is a useful predictor of CBD stones. These may be treated successfully by postoperative ERCP.

Do preoperative indicators predict the presence of common bile duct stones during laparoscopic cholecystectomy?

Criteria have been suggested to help decide if an intraoperative cholangiogram (IOC) should be performed during laparoscopic cholecystectomy (LC). They are a clinical history of passing a common bile duct (CBD) stone, elevated serum amylase, elevated liver function tests, or ultrasound findings suggesting a CBD stone. What is the sensitivity and specificity of the above criteria when the presence or absence of CBD stones is already known by IOC? What is the probability that these criteria will predict a CBD stone or be normal if a stone is absent, ie, the positive predictive value (PPV) and negative predictive value (NPV)? We reviewed 420 cases of elective LC done between May 1990 and December 1992. In our teaching hospital, IOC is routine and acted as the reference standard for the presence of CBD stones. All 420 films were reviewed as well as the results of any preoperative endoscopic retrograde cholangiopancreatography (ERCP) (30 were done). The following preoperative indicators of CBD stones were recorded: any clinical history of CBD stones; an elevated amylase, SGOT, alkaline phosphatase, or bilirubin level; and ultrasound findings. The sensitivity, specificity, PPV, and NPV were calculated. CBD stones were found in 12% of these elective LC cases. The sensitivity, specificity, PPV, and NPV, respectively, for each preoperative indicator were: a history suggestive of CBD stones (36%, 94%, 45%, and 91%), serum biochemistries as a group (43%, 86%, 30% and 91%), and ultrasound findings of CBD stones (22%, 92%, 28% and 89%). We compared any elevation versus > 2x from the normal range of the serum indicators and did not improve their accuracy. Combination of the indicators increased sensitivity and NPV but lowered specificity and PPV. The best predictor of CBD stones was the history (45%) and this was in a hospital with a CBD stone prevalence rate of 12%. There are no predictive tests that can sufficiently increase an observer's probability estimate of the presence or absence of CBD stones to allow for "selective" IOC decisions.