Adams Megan A, Hosmer Amy E, Wamsteker Erik J, Anderson Michelle A, Elta Grace H, Kubiliun Nisa M, Kwon Richard S, Piraka Cyrus R, Scheiman James M, Waljee Akbar K, Hussain Hero K, Elmunzer B Joseph
Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.
Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
Gastrointest Endosc. 2015 Jul;82(1):88-93. doi: 10.1016/j.gie.2014.12.023. Epub 2015 Mar 16.
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.
To assess the performance of existing guidelines in predicting choledocholithiasis and to determine whether trends in laboratory parameters improve diagnostic accuracy.
Retrospective cohort study.
Tertiary-care hospital.
Hospitalized patients presenting with suspected choledocholithiasis over a 6-year period.
Assessment of the American Society for Gastrointestinal Endoscopy (ASGE) guidelines, its component variables, and laboratory trends in predicting choledocholithiasis.
The presence of choledocholithiasis confirmed by EUS, MRCP, or ERCP.
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.
Retrospective study, inconsistent timing of the second set of biochemical markers.
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.
现有指南旨在对胆总管结石的可能性进行分层，以指导内镜逆行胰胆管造影（ERCP）的使用，而不是选择风险较低的诊断性检查，如超声内镜检查（EUS）、磁共振胰胆管造影（MRCP）或术中胆管造影。
评估现有指南在预测胆总管结石方面的性能，并确定实验室参数的变化趋势是否能提高诊断准确性。
回顾性队列研究。
三级医疗中心。
6年间因疑似胆总管结石而住院的患者。
评估美国胃肠内镜学会（ASGE）指南、其组成变量以及预测胆总管结石的实验室变化趋势。
通过EUS、MRCP或ERCP确诊的胆总管结石。
498例符合条件的患者中，共有179例（35.9%）在初次就诊时符合ASGE胆总管结石高概率标准。其中，99例患者（56.3%）在后续确诊检查中发现结石/胆泥。初次就诊时不符合高概率标准的患者中，111例（34.8%）有结石/胆泥。根据就诊时可得数据，该指南检测胆总管结石的总体准确率为62.1%（敏感性47.4%，特异性73%）。纳入入院后获得的第二组肝功能检查结果时，准确率未变（63.2%），这表明实验室变化趋势并未提高诊断性能。
回顾性研究，第二组生化标志物的检测时间不一致。
在我们的患者队列中，现有的胆总管结石指南缺乏诊断准确性，可能导致ERCP的过度使用。纳入实验室变化趋势并未提高诊断性能。需要开展更多聚焦于风险分层的研究，以实现消除不必要的诊断性ERCP这一目标。
