Preoperative predictors of choledocholithiasis in patients presenting with acute calculous cholecystitis

Published:November 19, 2018DOI:

      Background and Aims

      Markedly increased liver chemistries in patients presenting with acute calculous cholecystitis (AC) often prompt an evaluation for concomitant choledocholithiasis (CDL). However, current guidelines directing the workup for CDL fail to address this unique population. The aims of this study are to define the range of presenting laboratory values and imaging findings in AC, develop a model to predict the presence of concurrent CDL, and develop a management algorithm that can be easily applied on presentation.


      We conducted a retrospective review of patients presenting with AC to a large tertiary hospital over a 3.5-year period. CDL was defined as common bile duct (CBD) stone(s), sludge, or debris seen on any of the following studies: US, CT, magnetic resonance imaging/MRCP, EUS, ERCP, or intraoperative cholangiogram. A multivariable model to predict CDL was developed on 70% of the patients and validated on the remaining 30%.


      A total of 366 patients were identified and 65 (17.8%) had concurrent CDL. Univariable analysis was used to predict CDL and demonstrated statistically significant odds ratios for transaminases >3 times the upper limit of normal, alkaline phosphatase (AlkPhos) above normal, lipase >3 times the upper limit of normal, total bilirubin ≥1.8 mg/dL, and CBD diameter >6 mm. In the validation cohort, an optimal model containing alanine transaminase (ALT) >3 times the upper limit of normal, abnormal AlkPhos, and CBD diameter >6 mm was found to have an area under the receiver operating curve of 0.91. When 0 or 1 risk factors were present, 98.6% of patients did not have CDL. When all 3 risk factors were present, 77.8% were found to have CDL.


      The prevalence of CDL is high among patients with AC. When a validated model is used, application of cutoffs for ALT, AlkPhos, and CBD diameter can effectively triage patients with low and high likelihood for CDL to surgery or ERCP, respectively.

      Graphical abstract


      AC (acute calculous cholecystitis), AlkPhos (alkaline phosphatase), ALT (alanine transaminase), ASGE (American Society for Gastrointestinal Endoscopy), AST (aspartate transaminase), AUROC (area under the receiver operating curve), CBD (common bile duct), CDL (choledocholithiasis), CI (confidence interval), IOC (intraoperative cholangiogram), MRI (magnetic resonance imaging), OR (odds ratio)
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        • Strasberg S.M.
        Clinical practice. Acute calculous cholecystitis.
        N Engl J Med. 2008; 358: 2804-2811
        • Trowbridge R.L.
        • Rutkowski N.K.
        • Shojania K.G.
        Does this patient have acute cholecystitis?.
        JAMA. 2003; 289: 80-86
        • Al-Jiffry B.O.
        Non-invasive assessment of choledocholithiasis in patients with gallstones and abnormal liver function.
        World J Gastroenterol. 2013; 19: 5877
        • Maple J.T.
        • Ben-Menachem T.
        • Anderson M.A.
        • et al.
        • ASGE Standards of Practice Committee
        The role of endoscopy in the evaluation of suspected choledocholithiasis.
        Gastrointest Endosc. 2010; 71: 1-9
        • Song S.H.
        • Kwon C.I.
        • Jin S.M.
        • et al.
        Clinical characteristics of acute cholecystitis with elevated liver enzymes not associated with choledocholithiasis.
        Eur J Gastroenterol Hepatol. 2014; 26: 452-457
      1. Rosseland AR, Glomsaker TB. Asymptomatic common bile duct stones. Eur J Gastroenterol Hepatol 200;12:1171-3.

        • Tse F.
        • Barkun J.S.
        • Barkun A.N.
        The elective evaluation of patients with suspected choledocholithiasis undergoing laparoscopic cholecystectomy.
        Gastrointest Endosc. 2004; 60: 437-448
        • Sirinek K.R.
        • Schwesinger W.H.
        Has intraoperative cholangiography during laparoscopic cholecystectomy become obsolete in the era of preoperative endoscopic retrograde and magnetic resonance cholangiopancreatography?.
        J Am Coll Surg. 2015; 220: 522-528
        • Giljaca V.
        • Gurusamy K.S.
        • Takwoingi Y.
        • et al.
        Endoscopic ultrasound versus magnetic resonance cholangiopancreatography for common bile duct stones.
        Cochrane Database Syst Rev. 2015;
        • Ward W.H.
        • Fluke L.M.
        • Hoagland B.D.
        • et al.
        The role of magnetic resonance cholangiopancreatography in the diagnosis of choledocholithiasis: do benefits outweigh the costs?.
        Am Surg. 2015; 81: 720-725
        • Kaltenthaler E.
        • Vergel Y.B.
        • Chilcott J.
        • et al.
        A systematic review and economic evaluation of magnetic resonance cholangiopancreatography compared with diagnostic endoscopic retrograde cholangiopancreatography.
        Health Technol Assess. 2004; 8: 1-89
        • Morris S.
        • Gurusamy K.S.
        • Sheringham J.
        • et al.
        Cost-effectiveness analysis of endoscopic ultrasound versus magnetic resonance cholangiopancreatography in patients with suspected common bile duct stones.
        PLoS ONE. 2015; 10: e0121699
        • Netinatsunton N.
        • Attasaranya S.
        • Sottisuporn J.
        • et al.
        Comparing cost-effectiveness between endoscopic ultrasound and endoscopic retrograde cholangiopancreatography in diagnosis of common bile duct stone in patients with predefined risks: a study from a developing country.
        Endosc Ultrasound. 2016; 5: 165-172
        • Adams M.A.
        • Hosmer A.E.
        • Wamsteker E.J.
        • et al.
        Predicting the likelihood of a persistent bile duct stone in patients with suspected choledocholithiasis: accuracy of existing guidelines and the impact of laboratory trends.
        Gastrointest Endosc. 2015; 82: 88-93
        • Prachayakul V.
        • Aswakul P.
        • Bhunthumkomol P.
        • et al.
        Diagnostic yield of endoscopic ultrasonography in patients with intermediate or high likelihood of choledocholithiasis: a retrospective study from one university-based endoscopy center.
        BMC Gastroenterol. 2014; 14: 165
        • Abboud P.A.
        • Malet P.F.
        • Berlin J.A.
        • et al.
        Predictors of common bile duct stones prior to cholecystectomy: a meta-analysis.
        Gastrointest Endosc. 1996; 44: 450-455
        • Taylor T.V.
        • Armstrong C.P.
        • Rimmer S.
        • et al.
        Prediction of choledocholithiasis using a pocket microcomputer.
        Br J Surg. 1988; 75: 138-140
        • Huguier M.
        • Bornet P.
        • Charpak Y.
        • et al.
        Selective contraindications based on multivariate analysis for operative cholangiography in biliary lithiasis.
        Surg Gynecol Obstet. 1991; 172: 470-474
        • Peng W.K.
        • Sheikh Z.
        • Paterson-Brown S.
        • et al.
        Role of liver function tests in predicting common bile duct stones in acute calculous cholecystitis.
        Br J Surg. 2005; 92: 1241-1247
        • Yang D.
        • Yachimski P.
        When does assessment for bile duct stones need to be performed prior to cholecystectomy for calculus gallbladder disease?.
        Clin Gastroenterol Hepatol. 2018; 16: 331-332
        • Gurusamy K.S.
        • Giljaca V.
        • Takwoingi Y.
        • et al.
        Ultrasound versus liver function tests for diagnosis of common bile duct stones.
        Cochrane Database Syst Rev. 2015;
        • Geraghty J.M.
        • Goldin R.D.
        Liver changes associated with cholecystitis.
        J Clin Pathol. 1994; 47: 457-460
        • Chang C.-W.
        Acute transient hepatocellular injury in cholelithiasis and cholecystitis without evidence of choledocholithiasis.
        World J Gastroenterol. 2009; 15: 3788
        • Fikry A.
        Elevated liver enzymes in patients with cholecystitis.
        J Surg. 2014; 2: 38
        • Lee D.
        • Ahn Y.J.
        • Lee H.W.
        • et al.
        Prevalence and characteristics of clinically significant retained common bile duct stones after laparoscopic cholecystectomy for symptomatic cholelithiasis.
        Ann Surg Treat Res. 2016; 91: 239
        • Iranmanesh P.
        • Tobler O.
        • De Sousa S.
        • et al.
        Prospective validation of an initial cholecystectomy strategy for patients at intermediate-risk of common bile duct stone.
        Gastrointest Endosc. 2017; 85: 794-802
        • Almoner B.J.
        • Debenedet A.T.
        • Volk M.L.
        • et al.
        Clinical yield of diagnostic endoscopic retrograde cholangiopancreatography in orthotopic liver transplant recipients with suspected biliary complications.
        Liver Transpl. 2012; 18: 1479-1484
        • Cox M.R.
        • Budge J.P.O.
        • Eslick G.D.
        Timing and nature of presentation of unsuspected retained common bile duct stones after laparoscopic cholecystectomy: a retrospective study.
        Surg Endosc. 2015; 29: 2033-2038
        • Collins C.
        • Maguire D.
        • Ireland A.
        • et al.
        A prospective study of common bile duct calculi in patients undergoing laparoscopic cholecystectomy: natural history of choledocholithiasis revisited.
        Ann Surg. 2004; 239: 28-33
        • Padda M.S.
        • Singh S.
        • Tang S.J.
        • et al.
        Liver test patterns in patients with acute calculous cholecystitis and/or choledocholithiasis.
        Aliment Pharmakoi Ther. 2009; 29: 1011-1018
        • Kohn J.F.
        • Trenk A.
        • Kuchma K.
        • et al.
        Characterization of common bile duct injury after laparoscopic cholecystectomy in a high-volume hospital system.
        Surg Endosc. 2018; 32: 1184-1191
        • Wandling M.W.
        • Hungness E.S.
        • Pavey E.S.
        • et al.
        Nationwide assessment of trends in choledocholithiasis management in the United States from 1998 to 2013.
        JAMA Surg. 2016; 151: 1125-1130
        • Livingston E.H.
        • Rege R.V.
        Technical complications are rising as common duct exploration is becoming rare.
        J Am Coll Surg. 2005; 201: 426-433