ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis

Key points

• High-risk criteria that should prompt ERCP directly are a common bile duct stone on ultrasound or cross-sectional imaging, total bilirubin above 4 mg/dL with a dilated common bile duct (over 6 mm with the gallbladder in situ), or ascending cholangitis.
• In patients at intermediate risk (10%-50%), either endoscopic ultrasound (EUS) or magnetic resonance cholangiopancreatography (MRCP) is suggested (conditional recommendation, low-quality evidence).
• In gallstone pancreatitis without cholangitis or biliary obstruction, urgent ERCP within 48 hours is not recommended (strong recommendation, low-quality evidence).
• For large stones, large balloon dilation after sphincterotomy is suggested rather than sphincterotomy alone (conditional, moderate).
• Same-admission cholecystectomy is recommended for mild gallstone pancreatitis.

Overview

This American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice guideline gives GRADE-based recommendations on the endoscopic evaluation and treatment of bile duct stones. Its core is risk stratification, so that diagnostic endoscopic retrograde cholangiopancreatography (ERCP) is reserved for patients at high risk while others undergo less invasive tests first. The literature search ran from 21 September to 16 November 2017.

Risk stratification

High-risk patients go directly to ERCP. Intermediate-risk criteria are abnormal liver tests, age over 55 years or a dilated common bile duct on ultrasound; these patients should have EUS, MRCP, laparoscopic intraoperative cholangiography or laparoscopic intraoperative ultrasound. Patients with symptomatic gallstones and none of these risk factors are suggested to undergo cholecystectomy without intraoperative cholangiography. In the 2010 ASGE guideline, total bilirubin of 1.8-4.0 mg/dL with bile duct dilation, or bilirubin above 4 mg/dL alone, counted as high risk.

Timing with cholecystectomy

For patients at high risk or with a positive intraoperative cholangiogram, preoperative or postoperative ERCP or laparoscopic treatment is suggested, depending on local surgical and endoscopic expertise.

Large and difficult stones

For large and difficult stones, intraductal therapy or conventional therapy with papillary dilation is suggested (conditional, very low), depending on local expertise, cost and patient and physician preferences. In Mirizzi syndrome, peroral cholangioscopic therapy may be an alternative to surgery depending on local expertise, but the gallbladder must be removed regardless of strategy. Hepatolithiasis needs a multidisciplinary approach with endoscopy, interventional radiology and surgery. Plastic and covered metal stents may help remove difficult stones but require planned exchange or removal.

Frequently asked questions

When should a patient go straight to ERCP?

When a bile duct stone is seen on imaging, when total bilirubin is above 4 mg/dL with a dilated bile duct, or when ascending cholangitis is present.

Should ERCP be urgent in gallstone pancreatitis?

Not when there is no cholangitis or biliary obstruction; the guideline recommends against urgent ERCP within 48 hours in these patients.

What is suggested for patients at intermediate risk?

EUS or MRCP, chosen according to patient preference, local expertise and availability; laparoscopic intraoperative cholangiography or ultrasound are also options.

Source

ASGE Standards of Practice Committee; Buxbaum J, et al. ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis. Gastrointest Endosc 2019;89(6):1075-1105.e15. doi:10.1016/j.gie.2018.10.001. This summary was prepared by Medpresso from the original publication and is not a substitute for the full text or for medical advice.