Table 3:
Selected statements from guidelines on the management of patients with or suspected of having common bile duct stones
| Statement | Societies supporting the statement |
|---|---|
| The initial evaluation of patients suspected of having common bile duct stones should include the measurement of serum bilirubin and liver enzyme levels, and transabdominal ultrasonography of the right upper abdominal quadrant; on the basis of the results, patients are stratified into low, intermediate or high risk of having stones | ASGE17 BSG19 |
| Patients who have a low probability of common bile duct stones do not require ERCP preoperatively | ASGE17 NIH1 |
| Patients with an intermediate probability of common bile duct stones should be evaluated by means of endoscopic ultrasography, or magnetic resonance cholangiopancreatography, depending on local availability and cost | ACG20 AGA21 ASGE17,22 BSG19 |
| Avoidance of ERCP for diagnostic purposes is the best way to reduce the number of complications; ERCP should be avoided if there is a low probability of stones in the common bile duct | ACG20 ASGE17 BSG19 NIH1 |
| Magnetic resonance cholangiopancreatography, endoscopic ultrasonography and ERCP are sensitive and specific and are superior to transabdominal ultrasonography for the detection of common bile duct stones | ASGE22,23 BSG19 NIH1 |
| Endoscopic sphincterotomy and extraction of stones is successful in more than 90% of patients, with an overall complication rate of about 5% | ASGE23 |
| Balloon sphincteroplasty after a small sphincterotomy may be used as an alternative to biliary sphincterotomy in select patients | ASGE23 |
| If stone removal is unsuccessful, biliary decompression should be accomplished either with a stent or a nasobiliary drain | ASGE23 BSG19 |
| Laparoscopic exploration of the common bile duct or postoperative ERCP can be performed for the removal of stones when detected by means of other imaging modalities (e.g., intraoperative cholangiography, laparoscopic ultrasonography) |
ASGE17,23 BSG19 NIH1 |
| Multiple approaches exist regarding the sequence of steps in the management of patients with common bile duct stones; available resources and personnel should dictate the choice | SAGES24 |
| Biliary symptoms recur twice as often after sphincterotomy in patients whose gallbladder remains in situ compared with those who have their gallbladder removed | ASGE23 |
| Cholecystectomy should be performed after resolution of acute cholangitis or biliary pancreatitis if either condition develops in a patient with common bile duct stones | AGA21 BSG19 SSAT25 Tokyo Guidelines26 |
| Sphincterotomy and extraction of stones without subsequent cholecystectomy may benefit elderly patients with comorbidities that preclude the performance of cholecystectomy because of an increased risk of death | ACG20 AGA21 ASGE23 BSG19 |
| ERCP has no role in the diagnosis of acute pancreatitis except in patients with biliary pancreatitis and concomitant cholangitis or persistent biliary obstruction | ACG20 AGA21 ASGE17 BSG19 NIH1 |
| In pregnant patients, ERCP should be used only if therapeutic intervention is intended; biliary pancreatitis, common bile duct stones and cholangitis are the usual indications and can lead to fetal loss if not treated properly; the fetus should be shielded from the ionizing radiation and the lowest possible dose of radiation used | ASGE23 BSG19 SAGES27 |
Note: ACG = American College of Gastroenterology, AGA = American Gastroenterological Association, ASGE = American Society for Gastrointestinal Endoscopy, BSG = British Society of Gastroenterology, ERCP = endoscopic retrograde cholangiopancreatography, NIH = National Institute of Health, SAGES = Society of American Gastrointestinal and Endoscopic Surgeons, SSAT = Society for Surgery of the Alimentary Tract.