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Performance of the Choledocholithiasis Diagnostic Score in Patients with Acute Cholecystitis
Catarina Gouveia1, Rui Loureiro1, Rosa Ferreira1
1Serviço de Gastrenterologia, Hospital Beatriz Ângelo, Lisbon, Portugal.
Insights
The American Society for Gastrointestinal Endoscopy score is not reliable for screening common bile duct stones in patients with acute cholecystitis. A more sensitive method is recommended before endoscopic retrograde cholangiopancreatography.
Area of Science:
- Gastroenterology
- Hepatobiliary Surgery
Background:
- Choledocholithiasis affects 9-16.5% of patients with acute cholecystitis.
- No validated algorithms exist to predict choledocholithiasis in this patient group.
Purpose of the Study:
- Evaluate the performance of the American Society for Gastrointestinal Endoscopy choledocholithiasis diagnostic score in patients with acute cholecystitis.
Main Methods:
- Retrospective cross-sectional study over 4 years.
- Included patients with acute cholecystitis and ERCP, endoscopic ultrasound, MRCP, or intraoperative cholangiography.
Main Results:
- The high-risk score had 52% positive predictive value and 89% sensitivity.
- The intermediate-risk score had 22% positive predictive value and 11% sensitivity.
- Choledocholithiasis was confirmed in 51.6% of high-risk and 22.2% of intermediate-risk patients.
Conclusions:
- The choledocholithiasis diagnostic score has a lower positive predictive value in acute cholecystitis patients compared to general populations.
- The score is not recommended for screening common bile duct stones in this group.
- A sensitive diagnostic method should precede ERCP in patients with acute cholecystitis and suspected choledocholithiasis.
Introduction:
The prevalence of choledocholithiasis among patients with acute cholecystitis is estimated to be between 9 and 16.5%. There are no validated algorithms to predict choledocholithiasis in this group of patients.
Aim:
The aim of this study was to evaluate the performance of the choledocholithiasis diagnostic score proposed by the American Society for Gastrointestinal Endoscopy, in patients with acute cholecystitis.
Material/Methods:
A retrospective cross-sectional study, covering a 4-year period at a secondary care hospital, was performed. All patients with an encoded diagnosis of acute cholecystitis and with at least one of the following procedures were included: endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound, magnetic resonance cholangiopancreatography, and intraoperative cholangiography.
Results:
Among 4,369 patients with the diagnosis of acute cholecystitis, 40 (0.92%) had clinical or sonographic suspicion of choledocholithiasis. Their mean age was 68.1 ± 15 years, and 22 (55%) were men. Thirty-one of the patients included (77.5%) had a high risk of choledocholithiasis, and 9 (22.5%) had an intermediate risk. In 16 (51.6%) of the 31 patients with a high risk, the diagnosis of choledocholithiasis was confirmed. In 2 (22.2%) of the 9 patients with an intermediate risk, the diagnosis of choledocholithiasis was also confirmed. The high risk score for choledocholithiasis had a positive predictive value of 52% and a sensitivity of 89%. The intermediate risk score for choledocholithiasis had a positive predictive value of 22% and a sensitivity of 11%.
Discussion And Conclusions:
Suspicion of choledocholithiasis in patients with acute cholecystitis was a rare event (<1%). The sensitivity of the high risk score was approximately the same as found in published series with patients with suspected choledocholithiasis overall (86%), while the positive predictive value was substantially lower (52 vs. 79.8%). Therefore, in patients with acute cholecystitis and suspected choledocholithiasis, this score should not be used to screen for common bile duct stones, and a sensitive method should be used prior to ERCP.
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