title: Validation and improvement of a proposed scoring system to detect retained common bile duct stones in gallstone pancreatitis.
abstract: BACKGROUND
  In 2009, a study from our institution used retrospective data and multivariate analysis to identify 5 quantitative variables and their cutoffs that have a positive predictive value (PPV) for common bile duct (CBD) stones in gallstone pancreatitis. They also proposed a management protocol based on the scoring system. This prospective study sought to validate that scoring system.
  
  
  METHODS
  From October 2009 to August 2013, patients with gallstone pancreatitis were enrolled in the study. Scores of 0-5 were determined at admission, with 1 point for each criterion met: CBD ≥ 9 mm, gamma glutamyltransferase ≥ 350 U/L, alkaline phosphatase ≥ 250 U/L, total bilirubin ≥ 3 mg/dL, and direct bilirubin ≥ 2 mg/dL. All CBDs were assessed using intraoperative cholangiogram, MR cholangiopancreatography (MRCP), or endoscopic retrograde cholangiopancreatography (ERCP).
  
  
  RESULTS
  Of 84 patients, 16 had CBD stones. A score of 0 had negative predictive value (NPV) of 100% for CBD stones (P < .001). Scores of 1 and 2 had NPV of 81% and 83%, respectively. A score of 3 had NPV of 60%. A score of 4 had PPV of 67% (P = .002). A score of 5 had PPV of 100% (P < .001). The overall accuracy of the scoring system was 88%.
  
  
  CONCLUSIONS
  The scoring system is accurate in prediction of CBD stones in patients with gallstone pancreatitis. We propose that patients with 0 points undergo laparoscopic cholecystectomy, 1 and 2 points undergo laparoscopic cholecystectomy with intraoperative cholangiogram, 3 and 4 points undergo MRCP, and 5 points undergo ERCP as the first step in management for gallstone pancreatitis. The proposed protocol eliminated negative ERCPs.
authors.affiliation: Division of General Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY.
authors.forename: Jingjing L
authors.initials: JL
authors.lastname: Sherman
authors.affiliation: Division of General Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY.
authors.forename: Emily W
authors.initials: EW
authors.lastname: Shi
authors.affiliation: Division of General Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY.
authors.forename: Nalin E
authors.initials: NE
authors.lastname: Ranasinghe
authors.affiliation: Division of General Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY.
authors.forename: Muthu T
authors.initials: MT
authors.lastname: Sivasankaran
authors.affiliation: Division of General Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY.
authors.forename: Jake G
authors.initials: JG
authors.lastname: Prigoff
authors.affiliation: Division of General Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY. Electronic address: celia.divino@mountsinai.org.
authors.forename: Celia M
authors.initials: CM
authors.lastname: Divino
mesh_terms: D000046:Academic Medical Centers; D000328:Adult; D000368:Aged; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000379:methods; D017081:Cholecystectomy, Laparoscopic / Q000009:adverse effects / Q000379:methods*; D002985:Clinical Protocols / Q000592:standards*; D003135:Common Bile Duct / Q000000981:diagnostic imaging / Q000601:surgery; D005069:Evaluation Studies as Topic; D005260:Female; D005500:Follow-Up Studies; D042882:Gallstones / Q000150:complications / Q000175:diagnosis* / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative / Q000379:methods; D015999:Multivariate Analysis; D009519:New York City; D010195:Pancreatitis / Q000150:complications / Q000175:diagnosis* / Q000601:surgery*; D011183:Postoperative Complications / Q000000981:diagnostic imaging / Q000601:surgery; D011237:Predictive Value of Tests; D058996:Quality Improvement; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D016717:Sphincterotomy, Endoscopic / Q000009:adverse effects / Q000379:methods; D016896:Treatment Outcome