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Dynamic liver test patterns do not predict bile duct stones

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Abstract

Background

Numerous models have been developed to predict choledocholithiasis. Recent work has shown that these algorithms perform suboptimally. Identification of clinical predictors with high positive and negative predictive value would minimize adverse events associated with unnecessary diagnostic endoscopic retrograde cholangiopancreatography (ERCP) while limiting the use of expensive tests including magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound (EUS) for indeterminate cases.

Methods

Consecutive unique inpatients who received their first ERCP at Los Angeles County Medical Center between January 2010 and November 2016 for suspected bile duct stones were reviewed. The primary outcome was the proportion of patients with specific combinations of liver enzyme patterns, transabdominal ultrasound, and clinical features who had stones confirmed on ERCP. As a secondary outcome, we assessed the performance of the American Society for Gastrointestinal Endoscopy (ASGE) risk stratification algorithm in our population.

Results

Of the 604 included patients, bile duct stones were confirmed in 410 (67.9%). Detailed assessment of liver enzyme patterns alone and in combination with clinical features and imaging findings yielded no highly predictive algorithms. Additionally, the ASGE high-risk criterion had a positive predictive value of only 68% for stones. For the 236 patients for whom MRCP was performed, this imaging modality was shown to have highest predictive value for the presence of stones on ERCP.

Conclusion

Exhaustive exploration of various threshold values and dynamic patterns of liver enzymes combined with clinical features and basic imaging findings did not reveal an algorithm to accurately predict the presence of stones on ERCP. The ASGE risk stratification criteria were also insensitive in our population. Though desirable, there may be no “perfect” combination of clinical features that correlate with persistent bile duct stones. MRCP or EUS may be considered to avoid unnecessary ERCP and associated complications.

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Authors and Affiliations

  1. Department of Medicine, Keck School of Medicine, University of Southern California, D & T Building Room B4H100, 1983 Marengo St, Los Angeles, CA, 90033-1370, USA

    Chung Yao Yu, Nitzan Roth, Niraj Jani, Jaehoon Cho, Jacques Van Dam & James Buxbaum

  2. Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA

    Rick Selby

Authors
  1. Chung Yao Yu
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  2. Nitzan Roth
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  3. Niraj Jani
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  4. Jaehoon Cho
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  5. Jacques Van Dam
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  6. Rick Selby
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  7. James Buxbaum
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Contributions

CYY, NR, JB: concept and design. CYY, NR, NJ, JB: acquisition of data. CYY, NR, JB: statistical analysis and interpretation of data. CYY, NR, NJ, JC, JVD, RS, JB: drafting and revision of manuscript.

Corresponding author

Correspondence to James Buxbaum.

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Disclosures

Drs. Chung Yao Yu, Nitzan Roth, Niraj Jani, Jaehoon Cho, Jacques Van Dam, Rick Selby, and James Buxbaum have no conflicts of interest or financial ties to disclose.

Appendix

Appendix

See Tables 5, 6, 7, 8, 9, and 10.

Table 5 Univariate associations between the first set of liver enzyme values and ERCP findings
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Table 6 Univariate and multivariate associations between the last set of liver enzyme values and ERCP findings
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Table 7 Association of combined liver enzyme patterns with ERCP findings
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Table 8 Univariate association between liver enzyme trends with at least a 20% difference and ERCP findings
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Table 9 Univariate and multivariate associations between liver enzyme trends with absolute differences and ERCP findings
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Table 10 Association of simplified liver enzyme trends with ERCP findings
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Yu, C.Y., Roth, N., Jani, N. et al. Dynamic liver test patterns do not predict bile duct stones. Surg Endosc 33, 3300–3313 (2019). https://doi.org/10.1007/s00464-018-06620-x

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  • DOI: https://doi.org/10.1007/s00464-018-06620-x

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