title: Predicting the likelihood of a persistent bile duct stone in patients with suspected choledocholithiasis: accuracy of existing guidelines and the impact of laboratory trends.
abstract: BACKGROUND
  Existing guidelines aim to stratify the likelihood of choledocholithiasis to guide the use of ERCP versus a lower-risk diagnostic study such as EUS, MRCP, or intraoperative cholangiography.
  
  
  OBJECTIVE
  To assess the performance of existing guidelines in predicting choledocholithiasis and to determine whether trends in laboratory parameters improve diagnostic accuracy.
  
  
  METHODS
  Retrospective cohort study.
  
  
  METHODS
  Tertiary-care hospital.
  
  
  METHODS
  Hospitalized patients presenting with suspected choledocholithiasis over a 6-year period.
  
  
  METHODS
  Assessment of the American Society for Gastrointestinal Endoscopy (ASGE) guidelines, its component variables, and laboratory trends in predicting choledocholithiasis.
  
  
  METHODS
  The presence of choledocholithiasis confirmed by EUS, MRCP, or ERCP.
  
  
  RESULTS
  A total of 179 (35.9%) of the 498 eligible patients met ASGE high-probability criteria for choledocholithiasis on initial presentation. Of those, 99 patients (56.3%) had a stone/sludge on subsequent confirmatory test. Of patients not meeting high-probability criteria on presentation, 111 (34.8%) had a stone/sludge. The overall accuracy of the guidelines in detecting choledocholithiasis was 62.1% (47.4% sensitivity, 73% specificity) based on data available at presentation. The accuracy was unchanged when incorporating the second set of liver chemistries obtained after admission (63.2%), suggesting that laboratory trends do not improve performance.
  
  
  CONCLUSIONS
  Retrospective study, inconsistent timing of the second set of biochemical markers.
  
  
  CONCLUSIONS
  In our cohort of patients, existing choledocholithiasis guidelines lacked diagnostic accuracy, likely resulting in overuse of ERCP. Incorporation of laboratory trends did not improve performance. Additional research focused on risk stratification is necessary to meet the goal of eliminating unnecessary diagnostic ERCP.
authors: Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.
authors: Megan A
authors: MA
authors: Adams
authors: Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.
authors: Amy E
authors: AE
authors: Hosmer
authors: Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.
authors: Erik J
authors: EJ
authors: Wamsteker
authors: Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.
authors: Michelle A
authors: MA
authors: Anderson
authors: Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.
authors: Grace H
authors: GH
authors: Elta
authors: Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
authors: Nisa M
authors: NM
authors: Kubiliun
authors: Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.
authors: Richard S
authors: RS
authors: Kwon
authors: Division of Gastroenterology, Henry Ford Health System, Detroit, Michigan, USA.
authors: Cyrus R
authors: CR
authors: Piraka
authors: Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.
authors: James M
authors: JM
authors: Scheiman
authors: Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA; Veterans Affairs Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.
authors: Akbar K
authors: AK
authors: Waljee
authors: Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.
authors: Hero K
authors: HK
authors: Hussain
authors: Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA; Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA.
authors: B Joseph
authors: BJ
authors: Elmunzer
mesh_terms: D000465:Algorithms; D015415:Biomarkers / Q000097:blood; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000706:statistics & numerical data*; D049448:Cholangiopancreatography, Magnetic Resonance; D042883:Choledocholithiasis / Q000097:blood / Q000175:diagnosis*; D003661:Decision Support Techniques; D019160:Endosonography; D006801:Humans; D016015:Logistic Models; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D019564:Unnecessary Procedures / Q000706:statistics & numerical data*
chemical_list: D015415:Biomarkers