CBD Injury Classification
I need to clarify that the evidence provided addresses Common Bile Duct (CBD) injury classification in the context of biliary surgery and gallstone disease, not Cannabidiol-related injuries. The classification system for Common Bile Duct injuries follows a risk-stratification approach based on the likelihood of choledocholithiasis (common bile duct stones).
Risk Stratification for Common Bile Duct Stone Disease (CBDS)
Use the modified American Society of Gastrointestinal Endoscopy (ASGE) classification system to stratify patients into low, moderate, and high-risk categories for CBDS, which directly determines management approach. 1
Risk Classification Criteria
High Risk (>50% probability of CBDS)
Moderate Risk (10-50% probability of CBDS)
- Total serum bilirubin >4 mg/dL 1
- CBD diameter >6 mm (with gallbladder in situ) AND total serum bilirubin 1.8-4 mg/dL 1
- Abnormal liver biochemical tests other than bilirubin 1
- Age >55 years 1
- Clinical gallstone pancreatitis 1
Low Risk (<10% probability of CBDS)
- No predictors present 1
Management Algorithm Based on Risk Classification
High-Risk Patients
Proceed directly to diagnostic and therapeutic ERCP only if CBD stone is visualized on ultrasound. 1 This conservative modification from original ASGE guidelines prevents unnecessary ERCP complications, as up to 49% of patients classified as high-risk by bilirubin alone may not have stones. 1
Moderate-Risk Patients
Perform second-level imaging before intervention using one of the following modalities (based on local expertise and availability): 1
- Preoperative magnetic resonance cholangiopancreatography (MRCP) 1
- Preoperative endoscopic ultrasound (EUS) 1
- Intraoperative cholangiography (IOC) 1
- Laparoscopic ultrasound (LUS) 1
This approach avoids ERCP-related complications in patients without confirmed stones. 1
Low-Risk Patients
Proceed directly to cholecystectomy without further biliary investigation. 1
Initial Diagnostic Workup
Obtain liver function tests (LFTs) including ALT, AST, bilirubin, alkaline phosphatase (ALP), and GGT, plus abdominal ultrasound in all patients with suspected acute calculus cholecystitis (ACC). 1 This combination provides the foundation for risk stratification. 1
Key Ultrasound Findings
- CBD diameter >10 mm associates with 39% incidence of CBDS 1
- CBD diameter <9.9 mm associates with 14% incidence of CBDS 1
- CBD diameter alone is insufficient to identify significant CBDS risk and must be combined with clinical and laboratory parameters 1
Management of Difficult Stone Disease
When standard extraction techniques fail (including mechanical lithotripsy, endoscopic papillary balloon dilation with prior sphincterotomy, and cholangioscopy), consider the patient to have difficult stone disease. 1
Reserve percutaneous radiological stone extraction and open duct exploration for patients in whom endoscopic and laparoscopic techniques fail or are not possible. 1 Percutaneous extraction carries major complication rates of 3.6-6.8%. 1
Important Caveats
- The risk stratification system was not specifically developed for ACC patients, though it remains the best available tool 1
- Implementation of predictive scores in clinical practice remains poor despite validation 1
- The modified classification prioritizes avoiding ERCP complications over maximizing stone detection sensitivity 1
- Only 20% of bile duct explorations are currently performed laparoscopically, suggesting underutilization of this single-stage approach 1
Note: If your question pertained to Cannabidiol (CBD) product-related injuries rather than Common Bile Duct injuries, the provided evidence does not contain specific injury classification systems for cannabidiol. The cannabidiol literature focuses on adverse effects (hepatotoxicity, sedation, drug interactions) rather than injury classification schemes. 2, 3, 4