Comparing diagnostic accuracy of current practice guidelines in predicting choledocholithiasis: outcomes from a large healthcare system comprising both academic and community settings - 13/05/21

Doi : 10.1016/j.gie.2020.10.033

Aswathi Chandran, MD ¹, Shahrooz Rashtak, MD ¹, Prithvi Patil, MS ¹, Assaf Gottlieb, PhD ², Elmer Bernstam, MD ², Sushovan Guha, MD, PhD ¹, Srinivas Ramireddy, MD ¹, Ricardo Badillo, MD ¹, Roy Tomas DaVee, MD ¹, Lillian S. Kao, MD ³, Nirav Thosani, MD, MHA ^1,^⁎
¹ Center for Interventional Gastroenterology at UTHealth (iGUT), McGovern Medical School, UTHealth, Houston, Texas, USA
² School of Biomedical Informatics, UTHealth, Houston, Texas, USA
³ UTHealth, Houston, Texas, USA

^∗Reprint requests: Nirav Thosani, MD, MHA, Center for Interventional Gastroenterology at UTHealth (iGUT), McGovern Medical School, UTHealth, 6431 Fannin St, Houston, TX 77030.Center for Interventional Gastroenterology at UTHealth (iGUT)McGovern Medical SchoolUTHealth6431 Fannin StHoustonTX77030

Abstract

Background and Aims

The American Society for Gastrointestinal Endoscopy (ASGE) 2010 guidelines for suspected choledocholithiasis were recently updated by proposing more specific criteria for selection of high-risk patients to undergo direct ERCP while advocating the use of additional imaging studies for intermediate- and low-risk individuals. We aim to compare the performance and diagnostic accuracy of 2019 versus 2010 ASGE criteria for suspected choledocholithiasis.

Methods

We performed a retrospective chart review of a prospectively maintained database (2013-2019) of over 10,000 ERCPs performed by 70 gastroenterologists in our 14-hospital system. We randomly selected 744 ERCPs in which the primary indication was suspected choledocholithiasis. Patients with a history of cholecystectomy or prior sphincterotomy were excluded. The same patient cohort was assigned as low, intermediate, or high risk according to the 2010 and 2019 guideline criteria. Overall accuracy of both guidelines was compared against the presence of stones and/or sludge on ERCP.

Results

Of 744 patients who underwent ERCP, 544 patients (73.1%) had definite stones during ERCP and 696 patients (93.5%) had stones and/or sludge during ERCP. When classified according to the 2019 guidelines, fewer patients were high risk (274/744, 36.8%) compared with 2010 guidelines (449/744, 60.4%; P < .001). Within the high-risk group per both guidelines, definitive stone was found during ERCP more frequently in the 2019 guideline cohort (226/274, 82.5%) compared with the 2010 guideline cohort (342/449, 76.2%; P < .001). In our patient cohort, overall specificity of the 2010 guideline was 46.5%, which improved to 76.0% as per 2019 guideline criteria (P < .001). However, no significant change was noted for either positive predictive value or negative predictive value between 2019 and 2010 guidelines.

Conclusions

The 2019 ASGE guidelines are more specific for detection of choledocholithiasis during ERCP when compared with the 2010 guidelines. However, a large number of patients are categorized as intermediate risk per 2019 guidelines and will require an additional confirmatory imaging study.

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Graphical abstract

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Abbreviations : ASGE, CBD, IOC, NPV, PPV

Plan

Methods

Results

Performance of ASGE 2019 guidelines for choledocholithiasis

Performance of ASGE 2010 guidelines for choledocholithiasis

Comparing 2019 guideline criteria against 2010 guideline criteria

Performance characteristics of high-risk predictors

Discussion

	DISCLOSURE: The following authors disclosed financial relationships: S. Guha: Consultant for Medtronic. N. Thosani: Consultant for Boston Scientific, Medtronic, and Pentax America; speaker for Abbvie; royalties from Up-to-Date. All other authors disclosed no financial relationships. Research support for this study was provided in part by the Atilla Ertan MD endowment fund to Dr Nirav Thosani.
	See CME section, p. 1421.