- For patients with bile duct stones, patient selection is important to minimize endoscopic treatment complications.
- Save biliary endoscopy for those with the highest likelihood of ductal stones.
Why this matters
- In up to 15% of endoscopic retrograde cholangiopancreatography (ERCP)-guided bile duct stone treatments, major adverse events occur.
- American Society for Gastrointestinal Endoscopy (ASGE) Standard of Practice Guideline.
- With intermediate choledocholithiasis risk, diagnose using endoscopic ultrasound (EUS) or magnetic resonance cholangiopancreatography (MRCP; conditional recommendation; low-quality evidence [LQE]).
- For gallstone pancreatitis without cholangitis or biliary obstruction/choledocholithiasis, avoid urgent ERCP (strong recommendation, LQE).
- For large bile duct stones, use endoscopic sphincterotomy plus large balloon dilation, not endoscopic sphincterotomy alone (conditional recommendation, moderate-quality evidence).
- For large/difficult choledocholithiasis, use intraductal therapy or conventional therapy with papillary dilation (conditional recommendation, very LQE).
- For difficult choledocholithiasis, stents may help but require eventual exchange or removal.
- For mild gallstone pancreatitis, perform cholecystectomy during same admission.
- High-risk criteria prompting ERCP:
- Common bile duct (CBD) stone on ultrasound or cross-sectional imaging.
- Total bilirubin >4 mg/dL, dilated CBD.
- Ascending cholangitis.
- For cholecystectomy in patients with high choledocholithiasis risk or positive intraoperative cholangiography, perform pre- or postoperative ERCP or laparoscopic treatment.
- For Mirizzi syndrome, resect gallbladder; peroral cholangioscopic therapy could replace surgery.
- Hepatolithiasis requires multidisciplinary approach.