From the Guidelines
Up to 50% of gallstone pancreatitis cases are estimated to be caused by gallstones migrating to the common bile duct (CBD). This estimation is based on the updated guideline on the management of common bile duct stones (CBDS) published in the journal Gut in 2017 1. The clinical presentation of CBDS can vary, and while some patients may exhibit classical symptoms such as epigastric or right upper quadrant pain, jaundice, and/or fever, others may present with atypical abdominal symptoms that persist despite alternative forms of management. Key points to consider in the management of gallstone pancreatitis include:
- The potential for gallstones to cause ongoing biliary obstruction and complicate the clinical course if not identified and addressed
- The role of early endoscopic retrograde cholangiopancreatography (ERCP) in severe cases or when there is evidence of ongoing biliary obstruction
- The recommendation for cholecystectomy following resolution of the acute episode to prevent recurrence, given the high risk of recurrent gallstone pancreatitis without definitive treatment. It is essential to investigate for CBDS in patients with acute pancreatitis, as the presence of CBD stones can significantly impact the management and outcome of the disease 1.
From the Research
Gallstone Pancreatitis and CBD Stones
- The percentage of gallstone pancreatitis patients with associated common bile duct (CBD) stones is a significant concern in medical practice.
- According to a study published in 2005 2, 27% of patients with gallstone pancreatitis were found to have CBD stones confirmed by endoscopic retrograde cholangiopancreatography (ERCP).
- Another study from 1998 3 reported that 21% of patients with acute gallstone pancreatitis had persistent CBD stones.
- A more recent study from 2018 4 found that preoperative diagnosis, presence of a CBD stone on ultrasound, and age ≥ 60 years were associated with persistent CBD stones in patients with gallstone pancreatitis or choledocholithiasis.
Predictors of CBD Stones
- Serum total bilirubin on hospital day 2 was identified as the best predictor of CBD stones in a study from 1998 3, with a sensitivity of 90.5% and specificity of 63%.
- Elevated liver function tests and dilated CBD by ultrasound were also found to be accurate predictors of stones in a study from 1993 5.
- Age, liver function tests (LFTs), and ultrasound findings can help predict persistent CBD stones in patients initially presenting with gallstone pancreatitis or choledocholithiasis, as reported in a 2018 study 4.
Diagnosis and Management
- Magnetic resonance cholangiography (MRC) was found to be an effective noninvasive screening tool for CBD stones, with a sensitivity of 94% in a study from 2005 2.
- Endoscopic ultrasonography and MRC have high sensitivity, specificity, and accuracy for the diagnosis of CBD stones, as reported in a 2018 study 6.
- Endoscopic retrograde cholangiopancreatography (ERCP) is a useful diagnostic and therapeutic modality in patients with suspected CBD stones, as noted in a study from 1993 5.