Bile duct stones (choledocholithiasis)
Also known as: biliary colic · CBD stones · choledocholithiasis · cholelithiasis · common bile duct stones · gallstone disease
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ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis
ASGE (American Society for Gastrointestinal Endoscopy) · 2019
This ASGE guideline addresses the endoscopic evaluation and management of bile duct stones (note: choledocholithiasis specifically, rather than gallstone disease as a whole), including risk stratification and the role and timing of ERCP.
Endoscopic management of common bile duct stones: European Society of Gastrointestinal Endoscopy (ESGE) guideline
ESGE · 2019
The European Society of Gastrointestinal Endoscopy's guidance on stones in the common bile duct. It sets out how likely a stone is given blood tests and ultrasound, when to add MRCP or endoscopic ultrasound before committing to ERCP, and which endoscopic techniques to use for straightforward and for difficult stones. It also addresses what to do when a stone cannot be removed at the first attempt.
- Initial work-up is liver blood tests plus abdominal ultrasound; together these set the probability of a duct stone and drive the next step. source
- Where suspicion persists but ultrasound is not conclusive, endoscopic ultrasound or MRCP should be used before proceeding to ERCP. source
- Stone extraction is advised for every patient fit for the procedure, including those with no symptoms. source
- For difficult stones the preferred first approach is a limited sphincterotomy combined with large-balloon papillary dilation, with cholangioscopy-guided lithotripsy as a further option. source
- When a stone cannot be retrieved but drainage is needed, a temporary plastic biliary stent should be placed rather than leaving the duct obstructed. source
US vs EU key differences
- Risk stratification is quantified differently: ASGE defines explicit high-risk criteria (a duct stone on imaging, total bilirubin above 4 mg/dL with a dilated common bile duct, or ascending cholangitis) and numeric probability bands of high >50%, intermediate 10-50% and low <10%. ESGE instead derives likelihood qualitatively from liver function tests plus abdominal ultrasound, with no bilirubin cutoff attached to its algorithm. source
- Only the European guideline puts clocks on biliary drainage in acute cholangitis: ESGE ties timing to the 2018 Tokyo Guidelines severity grades, asking for drainage within 12 hours in septic shock, within 48-72 hours for moderate disease and electively for mild disease. The ASGE document has no equivalent graded timing schedule. source
- The two societies converge on difficult stones but not on how firmly: both favour sphincterotomy followed by large-balloon papillary dilation over sphincterotomy alone, yet ESGE grades this a strong recommendation on high-quality evidence while ASGE calls it conditional on moderate evidence. source
- Confidence in intraductal lithotripsy differs markedly: ESGE strongly recommends cholangioscopy-assisted electrohydraulic or laser lithotripsy for difficult stones on moderate-quality evidence, whereas ASGE only conditionally suggests intraductal therapy or conventional papillary dilation, on very-low-quality evidence and deferring to local expertise and cost. source
- Cholecystectomy timing is framed on different anchors: ESGE sets a concrete window of laparoscopic cholecystectomy within 2 weeks of ERCP for treated choledocholithiasis, while ASGE frames the question around gallstone pancreatitis and endorses same-admission cholecystectomy. source
What changed recently
- US2010 → 20192019-06-01
ASGE tightened its risk stratification for suspected choledocholithiasis: the high-probability group is now limited to ascending cholangitis, a stone seen on imaging, or bilirubin above 4 mg/dL together with a dilated bile duct, while acute pancreatitis and bilirubin of 1.8-4 mg/dL were dropped as predictors and the intermediate category was consolidated. The result is markedly higher specificity and fewer patients sent straight to diagnostic ERCP, with more directed first to EUS, MRCP or intraoperative cholangiography.
source ↗curation confidence 90%
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