title: Endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis: testing the current guidelines.
abstract: BACKGROUND
  Current guidelines include an algorithm for predicting choledocholithiasis. Presence of any very strong predictor or both strong predictors confers a high (>50%) probability of choledocholithiasis. Absence of predictors confers low risk (<10%) of choledocholithiasis. Other combinations have an intermediate risk of choledocholithiasis.
  
  
  OBJECTIVE
  Determine accuracy of the proposed algorithm in predicting choledocholithiasis.
  
  
  METHODS
  Retrospective analysis of all endoscopic retrograde cholangiopancreatographies performed for suspected choledocholithiasis in 3 years in a Tertiary care hospital and a community hospital serviced by The University of Texas Health Science Center at Houston Division of Gastroenterology. Application of the guidelines, and comparing results to endoscopic retrograde cholangiopancreatography findings.
  
  
  RESULTS
  A total of 1080 endoscopic retrograde cholangiopancreatographies were performed; 521 for choledocholithiasis. Most patients were Hispanic and female. Univariate analysis: presence of any very strong predictor and both strong predictors had an OR for choledocholithiasis of 3.30 and 2.36 respectively. Multivariate analysis: odds of choledocholithiasis with any very strong predictor was 2.87, and both strong predictors 3.24. Choledocholithiasis was present in 71.5%, and 41% of patients with high, and intermediate risk respectively.
  
  
  CONCLUSIONS
  This study confirms the utility of clinical predictors for the diagnosis of choledocholithiasis. All of the very strong predictors and one of the strong predictors increased the odds of choledocholithiasis. Patients with high risk for choledocholithiasis had a probability of 79% of choledocholithiasis. Sensitivity and specificity of current predictors are too low to obviate the possible need of non-invasive tests to confirm or exclude choledocholithiasis in all risk groups.
authors.affiliation: The University of Texas Health Science Center at Houston, Division of Gastroenterology, Hepatology and Nutrition, Houston, TX, United States. Electronic address: Moises.I.Nevah@uth.tmc.edu.
authors.forename: Moises Ilan Nevah
authors.initials: MI
authors.lastname: Rubin
authors.forename: Nirav C
authors.initials: NC
authors.lastname: Thosani
authors.forename: Rajasekhar
authors.initials: R
authors.lastname: Tanikella
authors.forename: David S
authors.initials: DS
authors.lastname: Wolf
authors.forename: Michael B
authors.initials: MB
authors.lastname: Fallon
authors.forename: Frank J
authors.initials: FJ
authors.lastname: Lukens
mesh_terms: D000465:Algorithms; D001663:Bilirubin / Q000097:blood; D002760:Cholangiopancreatography, Endoscopic Retrograde; D002761:Cholangitis / Q000150:complications; D042883:Choledocholithiasis / Q000097:blood / Q000150:complications / Q000175:diagnosis*; D003135:Common Bile Duct / Q000000981:diagnostic imaging; D005260:Female; D006764:Hospitals, Community; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D017410:Practice Guidelines as Topic / Q000592:standards*; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D012307:Risk Factors; D012680:Sensitivity and Specificity; D062606:Tertiary Care Centers; D014463:Ultrasonography
chemical_list: D001663:Bilirubin
keywords: Choledocholithiasis; Clinical predictors; Endoscopic retrograde cholangiopancreatography
references.citation: Gastrointest Endosc. 2005 Jan;61(1):86-97
references.pmid: 15672062
references.citation: Am J Surg. 1992 Jan;163(1):53-6; discussion 57-8
references.pmid: 1531107
references.citation: N Engl J Med. 1997 Jan 23;336(4):237-42
references.pmid: 8995085
references.citation: ANZ J Surg. 2008 Jun;78(6):487-91
references.pmid: 18522571
references.citation: Gastrointest Endosc. 2008 Apr;67(4):660-8
references.pmid: 18155205
references.citation: Surg Endosc. 2003 Nov;17(11):1705-15
references.pmid: 12958681
references.citation: Gastrointest Endosc. 2010 Jan;71(1):1-9
references.pmid: 20105473
references.citation: Gastroenterology. 1999 Sep;117(3):632-9
references.pmid: 10464139
references.citation: Eur J Gastroenterol Hepatol. 2007 Nov;19(11):1007-11
references.pmid: 18049172
references.citation: Am J Gastroenterol. 1998 Apr;93(4):527-31
references.pmid: 9576442
references.citation: Clin Gastroenterol Hepatol. 2005 Dec;3(12):1238-44
references.pmid: 16361050
references.citation: Lancet. 1988 Oct 29;2(8618):979-83
references.pmid: 2902491
references.citation: Arch Surg. 1995 Jun;130(6):625-30; discussion 630-1
references.pmid: 7763171
references.citation: Gastrointest Endosc. 2009 Feb;69(2):244-52
references.pmid: 19019364
references.citation: Surg Endosc. 2001 Jan;15(1):4-13
references.pmid: 11178753
references.citation: Am J Gastroenterol. 2007 Aug;102(8):1632-9
references.pmid: 17521400
references.citation: Gastroenterology. 2009 Feb;136(2):376-86
references.pmid: 19124023
references.citation: Endoscopy. 2007 Apr;39(4):296-303
references.pmid: 17427065
references.citation: Gastrointest Endosc. 1999 Mar;49(3 Pt 1):334-43
references.pmid: 10049417
references.citation: N Engl J Med. 1993 Jan 28;328(4):228-32
references.pmid: 8418402
references.citation: Ann Surg. 2001 Jul;234(1):33-40
references.pmid: 11420481