Preoperative Predictors of Choledocholithiasis in Patients Presenting with Acute Calculous Cholecystitis.Chisholm PR, Patel AH, Law RJ, Schulman AR, Bedi AO, Kwon RS, Wamsteker EJ, Anderson MA, Elta GH, Govani SM, Prabhu A. Gastrointest Endosc. 2018 Nov 19. [Epub ahead of print]

BACKGROUND AND AIMS:Markedly elevated 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 lab 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.

METHODS: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, MRI/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%.RESULTS:366 patients were identified, with 65 (17.8%) having concurrent CDL. Univariable analysis was used to predict CDL and demonstrated statistically significant odds ratios for transaminases >3-times upper limit of normal, alkaline phosphatase (AlkPhos) above normal, lipase >3-times upper limit of normal, total bilirubin >1.8 mg/dL, and CBD diameter >6 mm. In the validation cohort, an optimal model containing ALT >3-times upper limit of normal, abnormal AlkPhos and CBD diameter >6 mm was found to have an AUROC 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.CONCLUSIONS:Patients with AC have a high prevalence of choledocholithiasis. When a validated model is used, application of cutoffs for ALT, AlkPhos, and CBD diameter can effectively triage low and high likelihood patients for CDL to surgery or ERCP, respectively.

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