Choledocolithiasis

(Suspected) Choledocholithiasis Guideline

1. Initial evaluation of suspected choledocholithiasis should include serum liver biochemical tests and a transabdominal US of the right upper quadrant. These tests should be used to risk-stratify patients to guide further evaluation and management.
2. Patients with symptomatic cholelithiasis who are surgical candidates and have a low probability of choledocholithiasis should proceed to cholecystectomy without additional biliary evaluation.
3. Patients with an intermediate probability of choledocholithiasis should undergo further evaluation with preoperative EUS or MRC or an IOC. In this group of patients, we suggest that ERC be deferred unless EUS, MRC, and IOC are unavailable, given the less favorable risk profile of ERC.
4. Patients with a high probability of choledocholithiasis should undergo an evaluation of the bile duct with therapeutic capability, generally preoperative ERC. When available, laparoscopic bile duct exploration can serve as an alternative to ERC.
5. EUS or MRC can be considered in the diagnostic evaluation of post-cholecystectomy patients suspected of having choledocholithiasis when initial laboratory and US data are abnormal yet non-diagnostic.
6. Early ERC is not recommended in the evaluation and management of patients with mild ABP in the absence of clear evidence of a retained stone.
7. ERC is recommended in patients with acute biliary pancreatitis and concomitant cholangitis, given the observed benefits in morbidity and mortality.
8. Patients with acute biliary pancreatitis and clinical evidence of biliary obstruction may be considered for early ERC. Early ERC cannot be recommended for or against in patients with predicted severe acute biliary pancreatitis in the absence of overt biliary obstruction or cholangitis, given the lack of consensus in the available data.
9. As patients with acute biliary pancreatitis are at least at intermediate risk for choledocholithiasis, pre-operative EUS or IOC can be considered for these patients when cholangitis or biliary obstruction are absent.

This guideline has been promulgated by the American Society of Gastrointestinal Endoscopy and SAGES.