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.

Methods

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%.

Results

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.

Conclusions

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.

中文翻译：

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急性结石性胆囊炎患者胆总管结石的术前预测指标

背景和目标

患有急性结石性胆囊炎（AC）的患者肝化学物质显着增加，通常提示对伴随的胆总管结石症（CDL）进行评估。但是，目前指导CDL检查的指南未能解决这一独特的人群。这项研究的目的是定义在AC中呈现实验室值和影像学发现的范围，开发一种模型来预测并发CDL的存在，并开发一种可以轻松应用于演示的管理算法。

方法

我们对3.5年期间到一家大型三级医院接受AC治疗的患者进行了回顾性研究。CDL被定义为在以下任何一项研究中发现的胆总管结石，淤泥或碎屑：US，CT，磁共振成像/ MRCP，EUS，ERCP或术中胆道造影。70％的患者建立了预测CDL的多变量模型，其余30％的患者进行了验证。

结果

总共鉴定出366名患者，其中65名（17.8％）患有并发CDL。单变量分析用于预测CDL，并证明转氨酶>正常值的3倍，碱性磷酸酶（AlkPhos）高于正常值的上限，脂肪酶> 3倍>正常上限，总胆红素≥1.8 mg / dL， CBD直径> 6毫米。在验证队列中，发现包含丙氨酸转氨酶（ALT）>正常，异常AlkPhos上限上限的3倍且CBD直径> 6 mm的最优模型在接收器工作曲线下的面积为0.91。当存在0或1个危险因素时，98.6％的患者没有CDL。当所有3个危险因素均存在时，发现77.8％为CDL。

结论

AC患者中CDL的患病率很高。当使用经过验证的模型时，应用ALT，AlkPhos和CBD直径的临界值可以分别有效地将CDL手术或ERCP可能性低的患者分为三类。