Updated Criteria for Prediction of Choledocholithiasis Add Specificity

A variety of recommendations have been proposed for predicting choledocholithiasis based upon presenting signs, symptoms, initial laboratory studies, and imaging. In this retrospective study, the authors compared the performance of two such guidelines published by the American Society for Gastrointestinal Endoscopy (ASGE) in 2010 and 2019. 

Among more than 10,000 ERCPs performed in a 14-hospital system over 7 years, 744 cases were randomly selected from those performed for suspected choledocholithiasis, while excluding those with a prior cholecystectomy or sphincterotomy. Based on the criteria from the two guidelines, patients were categorized preprocedure as low, intermediate, or high risk for findings of duct stones or sludge. Overall, ERCP identified definite stones in 73.1% of patients and stone or sludge in 93.5% of cases. Fewer patients were classified as high risk by the 2019 guideline versus the 2010 guideline (36.8% vs 60.4%; P<.001), and more high-risk patients were found to have definitive stones, according to the 2019 guideline versus the 2010 guideline (82.5% vs 76.2%; P<.001). Overall specificity for stones was greater using the 2019 criteria (76% vs 46.5%; P<.001), yet the positive and negative predictive values were not significantly different between the two guidelines.