The diagnosis and management of common bile duct stones has evolved considerably in recent years. New endoscopic, radiologic and surgical techniques now provide doctors with a range of options. We present an evidence based approach which incorporates the latest technology and techniques to optimize outcomes for patients.

1. Evidence Based Approach To
Common Bile Duct (CBD) Stones
Dr Jarrod Lee
Gastroenterologist & Advanced Endoscopist
Mount Elizabeth Novena Hospital
Gastroentero-Hepatology Update 2013 @ Bandung 31st August 2013

2. Scope
• Overview
• Initial Assessment
• Further Evaluation
• Risk Stratified Diagnostic Approach
2
ASGE Guidelines 2010; BSG Guidelines 2008

3. Clinical Scenario
• 45 year female, no past medical history
• Presented with 2 days epigastric pain
• On arrival in emergency department,
pain had resolved
• Physical examination unremarkable
• Bilirubin 55 µmol/L; Amylase normal
• Trans abdominal ultrasound: multiple
gallbladder stones, CBD 9 mm but no
CBD stone
3

4. What Would You Do Next?
A. Computer Tomography (CT)
B. Magnetic Resonance Cholangiography
(MRCP)
C. Endoscopy Ultrasound (EUS)
D. Endoscopic Retrograde
Cholangiopancreatography (ERCP)
E. Laparoscopic cholecystectomy with
intraoperative cholangiogram (IOC)
4

5. Common Bile Duct
(CBD) Stones

6. CBD Stones
• Present in 10-20% of patients with symptomatic gallstones
• Most commonly results from passage of gallstones through
the cystic duct
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Complications
• Biliary
obstruction
• Cholangitis
• Pancreatitis
• Biliary cirrhosis

7. When to Suspect CBD Stones?
• Clinical presentation:
– abdominal pain, jaundice, nausea,
vomiting
• Cholangitis
• Acute pancreatitis
• Initial investigations:
– Liver Function Test (LFT)
– Trans abdominal Ultrasound (US)
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8. Liver Function Test
• Completely normal: NPV > 97%
• Abnormal: PPV 15%
• Bilirubin is the strongest predictor for
CBD stones; specificity varies
according to level
– Bilirubin ≥ 30 µmol/L: specificity 60%
– Bilirubin ≥ 68 µmol/L: specificity 75%
• Mean bilirubin in CBD stones: 25.5 –
32.3 µmol/L
8

9. Trans Abdominal Ultrasound
• First line imaging modality: widely
available, noninvasive, inexpensive
• CBD stones
– Poor sensitivity: 22-65%
– Specificity: 70-98%
• CBD dilatation
– Good sensitivity: 77-87%
– Dilated CBD: >6 mm with intact gallbladder
– Normal CBD: NPV 95-96%
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10. What is the Likelihood of CBD
Stones?
10

11. Clinical Predictors
• Very Strong:
– CBDS on US
– cholangitis
– bilirubin > 68 µmol/L
• Strong:
– dilated CBD on US
– bilirubin 30-68 µmol/L
• Moderate:
– other abnormal LFT
– gallstone pancreatitis
– age > 55 yrs
Likelihood of CBD
Stones:
• High (>50%):
– any very strong
predictor
– both strong predictors
• Low (<10%):
– no predictors
• Intermediate (10-
50%):
– all other patients
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12. What to do for the
Intermediate Group?
12

13. Further Investigations
• Radiologic
– CT: Computer Tomography
– MRCP: Magnetic Resonance Cholangiography
• Intraoperative:
– IOC: Intraoperative Cholangiogram
– Laparoscopic Ultrasound
• Endoscopic
– ERCP: Endoscopic Retrograde
Cholangiopancreatography
– EUS: Endoscopic Ultrasound
– IDUS: Intraductal Ultrasound
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14. Computer Tomography (CT)
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• Better sensitivity than US using
composite criteria
• Direct visualization < 75%
• Helical CT has improved
performance:
– Sensitivity: 71-85%
– Specificity: 88-97%
• Limited by expense, contrast &
radiation exposure

15. MRCP
• Sensitivity: 85-92%
• Specificity: 93-97%
• Can be used when ERCP and EUS not
possible, e.g. post surgical anatomy
• Decreased accuracy for small stones
<5 mm or large CBD >10 mm
– Sensitivity for small stones: 33 -71%
• Usual limitations of MRI
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16. Intraoperative Evaluation
• Intraoperative Cholangiogram (IOC)
– Successful in 88-100%
– Sensitivity: 59-100%
– Specificity: 93-100%
– Prolongs surgical procedure; needs fluoroscopy
• Laparoscopic US
– Sensitivity: 71-100%
– Specificity: 96-100%
– Technically difficult; longer learning curve
longer than IOC
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17. Endoscopic Evaluation
• ERCP
– Sensitivity 89-93%; Specificity 100%
– Significant risk of complications
• EUS
– Sensitivity 89-94%; Specificity 94-95%
– Highly sensitive for small stones; detects microlithiasis
– Complications rare
• IDUS
– Sensitivity 97-100%
– Clinical impact uncertain; probes expensive
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18. ERCP
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19. 19

20. Endoscopic Ultrasound
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21. 21
EUS – Mid CBD Stone

22. Stone Impacted at Ampulla
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EUS – Stone Impacted at Ampulla

23. Microlithiasis
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EUS – Microlithiasis

24. Which Modality to Choose?
Risk Stratified
Diagnostic Approach
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25. 25
Depends on costs and
local availability

26. 26
Diagnostic Approach

27. 27
Treatment Approach

28. Treatment Approach
• Cochrane Meta-analysis of 13 RCTs, N = 1351
– ERCP vs open surgery: open surgery had superior
stone clearance
– ERCP vs laparoscopic CBD exploration: similar
outcomes, morbidity & mortality
– Pre vs intra op ERCP: intra op ERCP had lower
morbidity
• In real life, laparoscopic CBD exploration & intra
op ERCP rarely practiced
28Cochrane Database Syst Rev 2006

29. 29
Endoscopic Approach

30. EUS Directed ERCP
• Start with EUS. If CBD stone found, proceed to
ERCP at same setting or within 1 day
• 4 RCTs to date: EUS directed ERCP vs ERCP
– Patients with intermediate to high risk for CBD stones
– Eliminates need for 60-73% of ERCP
– Overall less morbidity
– More cost effective when risk of CBDS 11-55%, i.e.
intermediate risk
• ?? Preferred approach
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31. Personal Audit
• 200 consecutive cases of EUS directed ERCP for
suspected CBD stones
– 64 patients with CBD stones
– 125 patients with normal CBD
– Sensitivity 100%; no missed stones
– Specificity 99.5%; 1 false positive
• 66% avoided unnecessary biliary procedure
• 11 patients with distal biliary strictures:
– 4 ampullary cancers, 5 cholangiocarcinomas, 2
pancreatic head cancers
31

32. Clinical Scenario
• 45 year female, no past medical history
• Presents with 2 days epigastric pain
• On arrival in emergency department,
pain had resolved
• Physical examination unremarkable
• Bilirubin 55 µmol/L; Amylase normal
• Trans Abdominal ultrasound: multiple
gallbladder stones, CBD 9mm but no
stones
32
Intermediate Probability for CBD Stones

33. What Would You Do Next?
A. Computer Tomography (CT)
B. Magnetic Resonance Cholangiography
(MRCP)
C. Endoscopy Ultrasound (EUS)
D. Endoscopic Retrograde
Cholangiopancreatography (ERCP)
E. Laparoscopic cholecystectomy with
intraoperative cholangiogram (IOC)
33
EUS Directed ERCP

34. Key Points
• An evidence based risk stratified approach to
suspected CBD stones balances the risk of
missed stones against procedural complications
• New technologies allow accurate imaging of the
CBD without risk of biliary instrumentation
• Management is dependent on costs, local
availability & expertise
34

35. Risk Stratified Approach
• Initial evaluation should include LFT &
Trans- abdominal US
• Subsequent management depends on
the probability of CBD stones:
– Low  laparoscopic cholecystectomy
– High  ERCP
– Intermediate  MRCP, EUS, IOC
• EUS directed ERCP is a promising new
approach for intermediate probability
patients
35

36. 36
Thank You
Questions?
drjarrodlee@gmail.com

37. Special Patient Groups
37

38. Post Cholecystectomy Patients
• Results from undetected migrated stone or
primary CBD stone
– Consider: bile leak, iatrogenic stricture, SOD
• Limited data for evaluation
• Incidence of CBD stone in suspected patients:
33-43%
• 6 mm cutoff for CBD size not appropriate
• EUS & MRCP shown to be highly accurate
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39. Gallstone Pancreatitis
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40. Diagnostic Evaluation
• Gallstones & microlithiasis are the most common
causes of acute pancreatitis
• 20% of acute pancreatitis will be classified as
‘idiopathic’ after US, CT & ERCP
• EUS:
– Maintains high accuracy for CBD stones: 97-100%
– Detects gallstones or microlithiasis in 75-80% of
acute pancreatitis classified as ‘idiopathic’
• EUS vs MRCP for severe pancreatitis
– EUS resulted in fewer ERCPs & complications
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41. Role of Early ERCP (24-72H)
• 3 RCTs showed trend towards benefit
– Significant benefit in severe pancreatitis
– Included patients with biliary obstruction & cholangitis
• Other trials showed no benefit
– 1 RCT showed no benefit in predicted severe
pancreatitis with bilirubin <85 µmol/L
– Recent meta-analysis excluding cholangitis showed no
benefit in severe pancreatitis
– 2 RCTs for pancreatitis with biliary obstruction but no
cholangitis had conflicting results
41

42. Early ERCP in Gallstone Pancreatitis
• No role for early ERCP in mild pancreatitis in
absence of retained stone
• Early ERCP recommended in gallstone
pancreatitis with cholangitis
• Conflicting data in biliary obstruction without
cholangitis, or in predicted severe pancreatitis
• Pre-op EUS or IOC recommended before
laparoscopic cholecystectomy if cholangitis or
biliary obstruction absent
42

43. EUS Directed ERCP
• 2 series in acute pancreatitis patients,
1 RCT vs direct ERCP
• EUS better than ERCP in detecting CBD
stones in acute pancreatitis
• Trend towards less morbidity with EUS
• No patients with negative EUS
developed recurrent symptoms in 2
year median follow up
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44. ‘Difficult’ Stone Disease
• Refers to stones > 1cm or
with distal stricture
• Endoscopic modalities:
– ‘Conventional’ treatment
– Extra-corporal shockwave
lithotripsy (ESWL)
– Electro-hydraulic lithotripsy
(EHL)
– Laser lithotripsy (LL)
– > 99% successful
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45. ‘Conventional’ Treatment
• Overall successful in > 90%
• Mechanical lithotripsy:
– Lower success in: impacted stones, stones > 2.5
cm, distal stricture
– Used for emergency ‘over the basket’ lithotripsy for
a large stone impacted in a standard basket
• Endoscopic papillary balloon dilation
– Can be combined with sphincterotomy
• Biliary stent insertion & repeat ERCP
– Higher success rate at repeat ERCP
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46. ESWL, EHL & LL
• ESWL
– Nasobiliary drain inserted for
targeting & drainage
– Adverse effects: pain,
hematoma, cholangitis
– Duct clearance 60-90%
• EHL & LL
– > 95% successful
– Used with cholangioscopy
– Expensive
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Thank You
Questions?
drjarrodlee@gmail.com