Updated Recommendations on Diagnosis and Management of Common Bile Duct Stones

David A. Johnson, MD reviewing Williams E et al. Gut 2017 Jan 25.

The British Society of Gastroenterology updates its 2008 guideline.

Sponsoring Organization: British Society of Gastroenterology

Target Audience: Gastrointestinal endoscopists and surgeons

Background and Objective

The incidence of common bile duct stones (CBDS) is estimated to be 5% to 10% among patients undergoing laparoscopic cholecystectomy for symptomatic cholelithiasis and 18% to 33% among patients with acute biliary pancreatitis. Endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction has been the first-line management strategy for CBDS. This British guideline updates evidence-based recommendations for CBDS management first published in 2008.

Key Recommendations

Use magnetic resonance cholangiopancreatography or endoscopic ultrasound, both highly recommended, in diagnosing CBDS in patients with intermediate probability of disease. The choice of test should be tailored to local expertise, test availability, and patient suitability.

Perform ERCP using propofol sedation or general anesthesia.

To reduce risk for post-ERCP pancreatitis (PEP), assuming no contraindications, administer rectal indomethacin 100 mg at the time of the procedure, and also insert a pancreatic stent if the patient has high risk for PEP.

Although endoscopic papillary balloon dilation in the absence of prior biliary sphincterotomy is associated with higher risk for PEP, consider performing it in selected high-risk patients (e.g., coagulopathy); if performed, use an 8-mm balloon.

Consider use of laparoscopic bile duct exploration (transductal or transcystic) for CBDS removal as it is associated with shorter length of stay compared with perioperative ERCP.

Perform cholecystectomy unless surgery risk is too high, in which case consider biliary sphincterotomy and stone extraction or biliary stent as an alternative.

Offer laparoscopic cholecystectomy to all patients following biliary pancreatitis and operate within 2 weeks, preferably during the index admission.

In patients with biliary pancreatitis who have associated cholangitis or persistent obstruction, perform ERCP with stone extraction within 72 hours of presentation.

COMMENT

These updated recommendations supplement the 2011 guideline from the American Society of Gastrointestinal Endoscopy on this topic. Particularly notable are the continued emerging standards regarding rectal indomethacin for PEP risk reduction, as well as the push to have cholecystectomy performed during the hospital admission for biliary pancreatitis.

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