University of Michigan Health Care System, Ann Arbor, Michigan, USA.
University of Michigan Health Care System, Ann Arbor, Michigan, USA; South Texas VA Healthcare System, San Antonio, Texas, USA; UT Health San Antonio, San Antonio, Texas, USA.
Gastrointest Endosc. 2019 May;89(5):977-983.e2. doi: 10.1016/j.gie.2018.11.017. Epub 2018 Nov 19.
Markedly increased liver chemistries in patients presenting with acute calculous cholecystitis (AC) often prompt an evaluation for concomitant choledocholithiasis (CDL). However, current guidelines directing the workup for CDL fail to address this unique population. The aims of this study are to define the range of presenting laboratory values and imaging findings in AC, develop a model to predict the presence of concurrent CDL, and develop a management algorithm that can be easily applied on presentation.
We conducted a retrospective review of patients presenting with AC to a large tertiary hospital over a 3.5-year period. CDL was defined as common bile duct (CBD) stone(s), sludge, or debris seen on any of the following studies: US, CT, magnetic resonance imaging/MRCP, EUS, ERCP, or intraoperative cholangiogram. A multivariable model to predict CDL was developed on 70% of the patients and validated on the remaining 30%.
A total of 366 patients were identified and 65 (17.8%) had concurrent CDL. Univariable analysis was used to predict CDL and demonstrated statistically significant odds ratios for transaminases >3 times the upper limit of normal, alkaline phosphatase (AlkPhos) above normal, lipase >3 times the upper limit of normal, total bilirubin ≥1.8 mg/dL, and CBD diameter >6 mm. In the validation cohort, an optimal model containing alanine transaminase (ALT) >3 times the upper limit of normal, abnormal AlkPhos, and CBD diameter >6 mm was found to have an area under the receiver operating curve of 0.91. When 0 or 1 risk factors were present, 98.6% of patients did not have CDL. When all 3 risk factors were present, 77.8% were found to have CDL.
The prevalence of CDL is high among patients with AC. When a validated model is used, application of cutoffs for ALT, AlkPhos, and CBD diameter can effectively triage patients with low and high likelihood for CDL to surgery or ERCP, respectively.
患有急性胆石性胆囊炎（AC）的患者肝功能检查明显升高，常促使对同时存在的胆总管结石（CDL）进行评估。然而，指导 CDL 检查的现行指南未能解决这一独特人群的问题。本研究旨在确定 AC 患者的实验室检查值和影像学表现范围，建立预测 CDL 存在的模型，并制定可在就诊时简便应用的管理算法。
我们对在 3.5 年内就诊于一家大型三级医院的 AC 患者进行了回顾性研究。CDL 的定义为在以下任何一项检查中发现的胆总管（CBD）结石、泥沙或碎片：US、CT、磁共振成像/磁共振胰胆管成像（MRCP）、EUS、ERCP 或术中胆管造影。在 70%的患者中建立了预测 CDL 的多变量模型，并在剩余的 30%患者中进行了验证。
共确定了 366 例患者，其中 65 例（17.8%）同时存在 CDL。单变量分析用于预测 CDL，并显示出肝功能检查中转氨酶（ALT）>正常值上限的 3 倍、碱性磷酸酶（AlkPhos）升高、脂肪酶（lipase）>正常值上限的 3 倍、总胆红素（total bilirubin）≥1.8mg/dL 和 CBD 直径>6mm 的比值比有统计学意义。在验证队列中，发现包含 ALT>正常值上限的 3 倍、AlkPhos 异常和 CBD 直径>6mm 的最优模型的接受者操作特征曲线下面积为 0.91。当存在 0 或 1 个危险因素时，98.6%的患者没有 CDL。当存在所有 3 个危险因素时，77.8%的患者存在 CDL。
AC 患者中 CDL 的患病率很高。当使用验证模型时，应用 ALT、AlkPhos 和 CBD 直径的截断值可以有效地将低和高 CDL 可能性的患者分诊至手术或 ERCP。
