Surgical Endoscopy and Other Interventional Techniques

https://doi.org/10.1007/s00464-022-09089-x

Accuracy of SAGES, ASGE, and ESGE criteria in predicting

choledocholithiasis
Kinzang Wangchuk1 · Pongsakorn Srichan1

Received: 30 August 2021 / Accepted: 29 January 2022

© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2022

Abstract
Background Patients with suspected choledocholithiasis (CDL) are stratified as high-risk (HR), intermediate-risk (IR),
and low-risk (LR) according to the guidelines of Society of American Gastrointestinal and Endoscopic Surgeons (SAGES),
American Society for Gastrointestinal Endoscopy (ASGE), and European Society of Gastrointestinal Endoscopy (ESGE).
Although these approaches are invaluable, paucity of validation studies are currently available. This study aimed to evaluate
the diagnostic accuracy of the above risk stratification criteria in predicting CDL.
Methods We conducted a retrospective cohort study of 280 patients with suspected CDL. All patients were stratified accord-
ing to above professional societies as HR, IR, and LR, and diagnostic performance was evaluated.
Results In the HR group, area under the receiver operating characteristic curve (AUC) were 0.77 [95% confidence interval
(CI), 0.70–0.84], 0.75 (95% CI, 0.68–0.81), and 0.74 (95% CI, 0.68–0.81) for SAGES, ASGE, and ESGE criteria, respec-
tively. The diagnostic accuracy were 78.93% (81.13% sensitivity, 72.06% specificity), 75% (75.47% sensitivity, 73.53%
specificity), and 70% (66.04% sensitivity, 82.35% specificity) for SAGES, ASGE, and ESGE criteria, respectively. Regard-
ing the IR group, the diagnostic accuracy were 22.50% (16.98% sensitivity, 39.71% specificity), 25% (24.53% sensitivity,
26.47% specificity), and 30.00% (33.49% sensitivity, 19.12% specificity) for SAGES, ASGE, and ESGE criteria, respectively.
The common bile duct stone (CBDS) visualized on imaging has the highest risk for CDL [odds ratio (OR), 13.59 (95% CI,
5.26–35.12)], followed by CBDS plus dilated common bile duct [OR, 13.33 (95% CI, 5.16–34.47)], CBDS plus cholangitis
[OR, 13.33 (95% CI, 3.17–56.15)], and CBDS plus total bilirubin level > 1.7 mg/dL [OR, 9.89 (95% CI, 3.47–28.20)].
Conclusions The current SAGES, ASGE, and ESGE criteria have acceptable diagnostic accuracy for CDL. The patients
with visualized CBDS on imaging have the highest risk for CDL.

Keywords Choledocholithiasis · Common bile duct stone · Biliary tract disease · Diagnostic accuracy · Validation

Choledocholithiasis (CDL) has a prevalence of approxi-
mately 10 to 20% in symptomatic gallstones, and < 5% are
encountered incidentally [1, 2]. In patients with CDL, 1/3
of the stones may pass spontaneously but the majority will
require endoscopic/surgical extraction of stones to prevent
complications such as pancreatitis, cholangitis, and jaun-
dice [2]. The SAGES, ASGE, and ESGE have published
guidelines with 3 risk stratification criteria based on the
presence of clinical, laboratory, and imaging predictors
for patients with suspected CDL [2–4]. These professional
societies aimed at optimizing the treatment approach and
* Kinzang Wangchuk
kinchhuk@icloud.com
1
Department of Surgery, Surin Hospital, Surin 32000,
Thailand
better utilization of various diagnostic and therapeutic
modalities for CDL, including magnetic resonance cholan-
giopancreatography (MRCP), endoscopic ultrasound (EUS),
endoscopic retrograde cholangiopancreatography (ERCP),
intraoperative cholangiogram (IOC), and laparoscopic
cholecystectomy.
The SAGES criterion has 4 risk factors; common bile
duct stone (CBDS) on imaging, dilated common bile
duct (CBD), ascending cholangitis, and total bilirubin
(TB) > 1.7 mg/dL. Patients with ≥ 2, 1, and 0 factors are
stratified as HR, IR, and LR, respectively. In ASGE crite-
rion, patients with CBDS on imaging, ascending cholangi-
tis, or TB > 4 mg/dL plus dilated CBD are stratified as HR.
The IR criteria include abnormal liver function tests (LFTs),
age > 55 year, or dilated CBD, and LR if none of these risk
factors are present. Regarding the ESGE criterion, patients

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are classified as follows: HR (has cholangitis or CBDS on
imaging), IR (has abnormal LFTs or dilated CBD), and
LR (none of these risk factors are present) (Table 1). The
intended pre-test probability in predicting CDL for HR, IR,
and LR group were 50–94%/5–50%/ < 5% for SAGES cri-
terion, and > 50%/10–50%/ < 10% for ASGE criterion [2,
3]. Although the above criteria are beneficial and widely
accepted for clinical practice, no study to date has validated
SAGES criterion, and to our best knowledge, only 2 stud-
ies have examined ASGE and ESGE criteria with varying
results [5, 6].
This study aims to validate the diagnostic accuracy of
SAGES, ASGE, and ESGE criteria, and analyze their indi-
vidual criteria in predicting CDL.
Materials and methods
We reviewed the patient’s chart retrospectively from Janu-
ary 2019 to December 2020 at Surin hospital, Thailand.
The study was commenced after receiving approval from
the institutional ethical committee. We searched in our elec-
tronic medical record database using ICD-10 diagnostic
codes including K80 (Cholelithiasis), K81 (Cholecystitis),
K82 (Other diseases of gallbladder), K83 (Other diseases
of biliary tract), and K87 (Disorders of gallbladder, biliary
tract, and pancreas in diseases classified elsewhere).
We included patients aged > 18-years-old with biliary
tract disease, and have undergone confirmatory testing
or therapeutic procedures for CDL (ERCP, MRCP, IOC
or CBD exploration). We excluded patients with biliary
pancreatitis, biliary strictures/stenosis, ampullary cancers,
cholangiocarcinoma, liver cirrhosis, viral hepatitis, chronic
alcoholism, and had previous surgical/endoscopic treatments
(cholecystectomy, ERCP with sphincterotomy, pancreatico-
biliary, and gastric surgery) (Fig. 1). We collected the demo-
graphic data, clinical presentations, vital signs, laboratory
results, ultrasound (US) and computed tomography (CT)
reports, and operative and endoscopic notes.
Statistical analysis
The baseline data are reported as mean, standard deviation,
and percentage. All patients were categorized into HR, IR,
or LR according to the SAGES, ASGE, and ESGE criteria,
and their diagnostic ability was evaluated with AUC (C-sta-
tistic). The sensitivity and specificity, PPV and NPV, posi-
tive likelihood ratio and negative likelihood ratio, accuracy,
and OR were calculated. The data analysis was performed
by using Microsoft Excel 2010, SPSS for Windows (ver-
sion 23.0.0; IBM Corporation, Chicago, IL), and Medcalc
version 20.099.
Results
Patient characteristics
A total of 1098 patients were assessed for eligibility. After
excluding 818 patients, 280 patients were included for the
final analysis. The mean (± standard deviation) age of the
patients was 66.45 (± 15.10) years, and 153 (54.64%) were

Table 1  Comparison of SAGES, ASGE, and ESGE criteria in predicting choledocholithiasis [2–4]
SAGES criterion ASGE criterion ESGE criterion

High-risk
Recommendations
Intermediate-risk
Recommendations
Low-risk
Recommendations
Any 2 risk factors: Any 1 risk factors: Any 1 risk factors:
1. CBDS on imaging 1. CBDS on imaging 1. CBDS on imaging
2. Cholangitis 2. Cholangitis 2. Cholangitis
3. Dilated CBD 3. TB > 4 mg/dL plus dilated CBD
4. TB > 1.7 mg/dL
ERCP or LC with CBDE ERCP ERCP or LC with CBDE
Any 1 risk factors: Any 1 risk factors: Any 1 risk factors:
1. CBDS on imaging 1. Abnormal LFTs 1. Abnormal LFTs
2. Cholangitis 2. Age > 55 years 2. Dilated CBD
3. Dilated CBD 3. Dilated CBD
4. TB > 1.7 mg/dL
IOC or MRCP or EUS EUS or MRCP or IOC or IOUS EUS or MRCP
No risk factors No risk factors No risk factors
LC LC with or without IOC or IOUS LC

ASGE American Society for Gastrointestinal Endoscopy, CBD common bile duct, CBDE common bile duct exploration, CBDS common bile
duct stone, ERCP endoscopic retrograde cholangiopancreatography, ESGE European Society of Gastrointestinal Endoscopy, EUS endoscopic
ultrasound, IOC intraoperative cholangiogram, IOUS intraoperative ultrasound, LC laparoscopic cholecystectomy, LFTs liver function tests,
MRCP magnetic resonance cholangiopancreatography, SAGES Society of American Gastrointestinal and Endoscopic Surgeons, TB total biliru-
bin

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Table 2  Baseline characteristics of the study population (n = 280)

Age, mean ± standard deviation, years 66.45 ± 15.10

Male sex, n (%) 153 (54.64)
Age > 55 year, n (%) 208 (74.29)
Ascending cholangitis, n (%) 100 (35.71)
Laboratory results, n (%)
TB > 1.2 mg/dL 227 (81.07)
TB > 1.7 mg/dL 198 (70.71)
TB > 4 mg/dL 114 (40.71)
AST (M ≥ 50 UI/L, F ≥ 35 UI/L) 223 (79.64)
ALT (M ≥ 50 UI/L, F ≥ 35 UI/L) 205 (73.21)
ALP > 120 UI/L 222 (79.29)
Abnormal LFTs 260 (92.86)
Initial imaging modalities, n (%)
Abdominal US 254 (90.71)
Abdominal CT scan 26 (9.29)
Findings on imaging, n (%)
Cholelithiasis 163 (58.21)
Acute cholecystitis 103 (36.79)
Chronic cholecystitis 10 (3.57)
CBD obstruction 51 (18.21)
Fig. 1  Enrollment algorithm for the study population. ASGE Ameri-
can Society for Gastrointestinal Endoscopy, ERCP endoscopic retro- Dilated CBD (> 6 mm) 219 (78.21)
grade cholangiopancreatography, ESGE European Society of Gastro- Choledocholithiasis
intestinal Endoscopy, SAGES Society of American Gastrointestinal Stone with or without sludge 114 (40.71)
and Endoscopic Surgeons
Sludge only 1 (0.36)
Confirmatory testing for choledocholithiasis, n (%)
ERCP 120 (42.86)
male. There were 254 (90.71%) and 26 (9.29%) patients who
MRCP 90 (32.14)
underwent abdominal US and CT scans, respectively. The
CBDE 58 (20.71)
findings on imaging were dilated CBD in 219 (78.21%),
IOC 12 (4.29)
CBDS in 114 (40.71%), CBD sludge in 1 (0.36%), cholelith-
Confirmed choledocholithiasis, n (%) 212 (75.71)
iasis in 163 (58.21%), acute cholecystitis in 103 (36.79%),
chronic cholecystitis in 10 (3.57%), and CBD obstruction in ALP alkaline phosphatase, ALT alanine aminotransferase, AST aspar-
51 (18.21%). There were 100 (35.71%) patients diagnosed tate transaminase, CBD common bile duct, CBDE common bile duct
exploration, CT computed tomography, ERCP endoscopic retrograde
with ascending cholangitis. A total of 212 (75.71%) patients cholangiopancreatography, F female, IOC intraoperative cholangio-
were confirmed to have CBDS by definitive testing [ERCP gram, LFTs liver function tests, M male, MRCP magnetic resonance
in 120 (42.86%), MRCP in 90 (32.14%), CBD exploration cholangiopancreatography, TB total bilirubin, US ultrasound
in 58 (20.71%), and IOC in 12 (4.29%)] (Table 2).

Diagnostic performance of SAGES, ASGE, and ESGE
criteria
The patients in HR, IR, and LR were 191 (68.21%)/77
(27.50%)/12 (4.29%) for SAGES criterion, 178 (63.57%)/102
(36.43%)/0 (0%) for ASGE criterion, and 152 (54.29%)/126
(45.00%)/2 (0.71%) for ESGE criterion (Fig. 1). The AUC
were 0.77 (95% CI, 0.70–0.84), 0.75 (95% CI, 0.68–0.81),
and 0.74 (95% CI, 0.68–0.81) for SAGES, ASGE, and
ESGE HR criteria, respectively (Fig. 2). The diagnostic
accuracy were 78.93% (81.13% sensitivity, 72.06% speci-
ficity), 75% (75.47% sensitivity, 73.53% specificity), and
70% (66.04% sensitivity, 82.35% specificity) for SAGES,
ASGE, and ESGE criteria, respectively. The PPV and NPV
were 90.05%/55.06%, 89.89%/49.02%, and 92.11%/43.75%,
respectively.
Regarding the IR group, the diagnostic accuracy were
22.50% (16.98% sensitivity, 39.71% specificity), 25%
(24.53% sensitivity, 26.47% specificity), and 30.00%
(33.49% sensitivity, 19.12% specificity) for SAGES,
ASGE, and ESGE criteria, respectively. The PPV and
NPV were 46.75%/13.30%%, 50.98%/10.11%, and
56.35%/8.44% for SAGES, ASGE, and ESGE criterion,
respectively (Table 3).

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Fig. 2  Receiver operating

characteristic (ROC) curve of
SAGES, ASGE, and ESGE
high-risk criteria in predict-
ing choledocholithiasis. ASGE
American Society for Gastroin-
testinal Endoscopy, ESGE Euro-
pean Society of Gastrointestinal
Endoscopy, SAGES Society of
American Gastrointestinal and
Endoscopic Surgeons

Table 3  Performance of SAGES, ASGE, and ESGE criteria in predicting choledocholithiasis, % (95% CI)
Criteria Sensitivity Specificity PPV NPV PLR NLR Accuracy

SAGES (High- 81.13 (75.21– 72.06 (59.85– 90.05 (86.01– 55.06 (47.18– 2.90 (1.97–4.28) 0.26 (0.19–0.36) 78.93 (73.68–
risk) 86.17) 82.27) 93.02) 62.69) 83.56)
ASGE (High- 75.47 (69.11– 73.53 (61.43– 89.89 (85.59– 49.02 (42.19– 2.85 (1.90–4.27) 0.33 (0.25–0.44) 75.00 (69.50–
risk) 81.11) 83.50) 93.01) 55.89) 79.96)
ESGE (High- 66.04 (59.24– 82.35 (71.20– 92.11 (87.37– 43.75 (38.49– 3.74 (2.22–6.31) 0.41 (0.33–0.51) 70.00 (64.26–
risk) 72.38) 90.53) 95.16) 49.16) 75.31)
SAGES (Inter- 16.98 (12.19– 39.71 (28.03– 46.75 (38.11– 13.30 (10.21– 0.28 (0.20–0.40) 2.09 (1.55–2.82) 22.50 (17.74–
mediate-risk) 22.73) 52.30) 55.59) 17.14) 27.85)
ASGE (Interme- 24.53 (18.89– 26.47 16.50– 50.98 (44.11– 10.11 (6.99– 0.33 (0.25–0.44) 2.85 (1.90–4.27) 25.00 (20.04–
diate-risk) 30.89) 38.57 57.81) 14.41) 30.50)
ESGE (Interme- 33.49 (27.17– 19.12 (10.59– 56.35 (50.83– 8.44 (5.31–13.17) 0.41 (0.33–0.52) 3.48 (2.11–5.73) 30.00 (24.69–
diate-risk) 40.28) 30.47) 61.72) 35.74)
SAGES (Low- 1.89 (0.52–4.76) 88.24 (78.13– 33.33 (13.45– 22.39 (20.88– 0.16 (0.05–0.52) 1.11 (1.02–1.22) 22.86 (18.07–
risk) 94.78) 61.67) 23.97) 28.23)
ASGE (Low- 0.00 (0.00–1.72) 100.00 (94.72– – 24.29 (24.29– – 1.00 (1.00–1.00) 24.29 (19.38–
risk) 100.00) 24.29) 29.74)
ESGE (Low- 0.47 (0.01–0.60) 98.53 (92.08– 50.00 (5.96– 24.10 (23.55– 0.32 (0.02–5.06) 1.01 (0.98–1.04) 24.29 (19.38–
risk) 99.96) 94.04) 24.66) 29.74)

ASGE American Society for Gastrointestinal Endoscopy, CI confidence interval, ESGE European Society of Gastrointestinal Endoscopy, NLR
negative likelihood ratio, NPV negative predictive value, PLR positive likelihood ratio, PPV positive predictive value, SAGES Society of Ameri-
can Gastrointestinal and Endoscopic Surgeons

Diagnostic performance of individual variables CI, 5.26–35.12), followed by CBDS plus dilated CBD [OR,
13.33 (95% CI, 5.16–34.47)], CBDS plus cholangitis [OR,
For individual variables, patients with visualized CBDS 13.33 (95% CI, 3.17–56.15)], and CBDS plus TB > 1.7 mg/
on imaging had the highest risk for CDL (OR, 13.59; 95% dL [OR, 9.89 (95% CI, 3.47–28.20)] (Table 4).

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Table 4  Diagnostic performance of individual criteria in predicting choledocholithiasis, % (95% CI)

Criteria Sensitivity Specificity PPV NPV PLR NLR Accuracy OR

Age > 55 years 77.36 (71.13– 35.29 (24.08 78.85 (75.50– 33.33 (24.98– 1.20 (0.99– 0.64 (0.43– 67.14 (61.30– 1.86
82.81) 47.83) 81.84) 42.89) 1.45) 0.96) 72.62) (1.03–3.37)
Cholangitis 42.9 (236.17– 86.76 (76.36– 91.00 (84.36– 32.78 (29.58– 3.24 (1.73– 0.66 (0.57– 53.57 (47.54– 4.93 (2.32–
49.88) 93.77) 94.99) 36.14) 6.08) 0.76) 59.53) 10.46)
CBDS on imag- 51.89 (44.94– 92.65 (83.67– 95.65 (90.36– 38.18 (34.60– 7.06 (3.01– 0.52 (0.44– 61.79 (55.82– 13.59 (5.26–
ing 58.78) 97.57) 98.10) 41.90) 16.57) 0.61) 67.50) 35.12)
Dilated 87.74 (82.55– 51.47 (39.03– 84.93 (81.45– 57.38 (46.74– 1.81 (1.41– 0.24 (0.16– 78.93 (73.68– 7.59 (4.05–
CBD > 6 mm 91.83) 63.78) 87.86) 67.37) 2.32) 0.37) 83.56) 14.22)
TB > 1.7 mg/dL 73.58 (67.11– 38.24 (26.71– 78.79 (75.19– 31.71 (24.16– 1.19 (0.97– 0.69 (0.47– 65.00 (59.10– 1.72
79.39) 50.82) 81.99) 40.35) 1.46) 1.01) 70.58) (0.97–3.07)
Abnormal LFTs 94.81 (90.91– 13.24 (6.23– 77.31 (75.54– 45.00 (26.15– 1.09 (0.99– 0.39 (0.17– 75.00 (69.50– 2.79
97.38) 23.64) 78.98) 65.40) 1.21) 0.91) 79.96) (1.10–7.05)
CBDS plus 51.42 (44.47– 92.65 (83.67– 95.61 (90.27– 37.95 (34.40– 6.99 (2.98– 0.52 (0.45– 61.43 (55.45– 13.33 (5.16–
dilated CBD 58.32) 97.57) 98.08) 41.63) 16.42) 0.61) 67.16) 34.47)
CBDS plus 28.77 (22.78– 97.06 (89.78– 96.83 (88.45– 30.41 (28.44– 9.78 (2.46– 0.73 (0.67– 45.36 (39.42– 13.33 (3.17–
cholangitis 35.37) 99.64) 99.18) 32.46) 38.95) 0.81) 51.39) 56.15)
CBDS plus 38.21 (31.64– 94.12 (85.62– 95.29 (88.51– 32.82 (30.20– 6.50 (2.47– 0.66 (0.58– 51.79 (45.76– 9.89 (3.47–
TB > 1.7 mg/ 45.11) 98.37) 98.16) 35.55) 17.07) 0.74) 57.77) 28.20)
dL
Dilated 36.79 (30.29– 80.88 (69.53– 85.71 (78.11– 29.10 (26.02– 1.92 (1.14– 0.78 (0.67– 47.50 (41.53– 2.46
CBD plus 43.67) 89.41) 90.98) 32.39) 3.24) 0.91) 53.53) (1.27–4.79)
TB > 4 mg/dL
Dilated CBD 39.62 (32.99– 91.18 (81.78– 93.33 (86.50– 32.63 (29.80– 4.49 (2.05– 0.66 (0.58– 52.14 (46.12– 6.78 (2.80–
plus Cholan- 46.55) 96.69) 96.84) 35.59) 9.81) 0.76) 58.12) 16.38)
gitis
Dilated 63.68 (56.81– 76.47 (64.62– 89.40 (84.45– 40.31 (35.11– 2.71 (1.74– 0.47 (0.38– 66.79 (60.93– 5.70 (3.05–
CBD plus 70.16) 85.91) 92.91) 45.74) 4.20) 0.59) 72.28) 10.66)
TB > 1.7 mg/
dL
Cholangitis plus 37.26 (30.74– 88.24 (78.13– 90.80 (83.43– 31.09 (28.27– 3.17 (1.61– 0.71 (0.62– 49.64 (43.64– 4.45
TB > 1.7 mg/ 44.15) 94.78) 95.09) 34.06) 6.21) 0.81) 55.65) (2.02–9.80)
dL

CBD common bile duct, CBDS common bile duct stone, CI confidence interval, LFTs liver function tests, PLR positive likelihood ratio, NLR
negative likelihood ratio, NPV negative predictive value, OR odds ratio, PPV positive predictive value, TB total bilirubin

Discussion Our results demonstrated that the AUC were 0.77,

In this current study, we investigated the diagnostic ability
of risk stratification criteria (HR, IR, and LR), developed
by 3 professional societies in predicting CDL. Our study
confirms the intended pre-test probability of these criteria
in identifying CDL. The SAGES criterion had identified
CDL in 81.13%, 16.98%, and 1.89% for HR, IR, and LR,
respectively, demonstrating the desired intent of predict-
ing CDL of 50–94% for HR, 5–50% for IR, and < 5% for
LR [2]. The ASGE criterion in our study yielded 75.47%,
24.53%, and 0.00% of patients with CDL, achieving the
target of > 50%, 10–50%, and < 10% for HR, IR, and LR,
respectively [3]. The ESGE criterion detected CDL in
66.04%, 33.49%, and 0.47% for HR, IR, and IR, respec-
tively, but according to our findings, no data was available
for the intended target of identification [4].
0.75, and 0.74 for SAGES, ASGE, and ESGE HR criteria,
respectively. All 3 criteria have acceptable diagnostic abil-
ity for CDL, defined by the AUC range of 0.7 to 0.8 [7].
The SAGES criterion has shown slightly higher diagnostic
ability than ASGE and ESGE criteria, although not sta-
tistically significant [ASGE vs ESGE (p = 0.901), ASGE
vs SAGES (p = 0.116), ESGE vs SAGES (p = 0.269)].
The sensitivities were 75.47% and 66.04% for ASGE and
ESGE HR criteria, respectively, showing similar results
published by Jagtap et al. (sensitivity, 74.64% for ASGE
criterion and 74.28% for ESGE criterion) [6]. The specifi-
cities of HR were 73.53% for ASGE criterion and 82.35%
for ESGE criteria, yielding comparable results reported
by Reddy et al. (specificity, 83.4% for ASGE criterion and
87.3% for ESGE criterion) [5]. Regarding the SAGES cri-
terion, we could not make any comparison because to our
best knowledge, current study is the first to validate it.

13

Among the individual variables, CBDS on imaging has
been found to have the highest risk (OR, 13.59) for CDL,
consistent with previous studies [6, 8, 9].
According to our study, the management for CDL using
these 3 criteria was confirmed to be acceptable. However,
we have a concern in the HR group where ERCP is rec-
ommended without need for further confirmatory testing.
Although ERCP is a gold standard for the diagnosis and
management of CDL, it is also technically challenging
and accompanied by significant complications ranging
from 6 to 10% [10–12]. Currently, there are more accurate
and non-invasive diagnostic modalities for CDL includ-
ing EUS (sensitivity, 95%; specificity, 97%) and MRCP
(sensitivity, 93%; specificity, 96%) [13]. Taking this into
consideration, when the presence of CDL is not definite,
confirmatory testing with EUS or MRCP may be useful
prior to ERCP. If HR criteria were applied to our study
population, the rate of diagnostic ERCP would be 27.94%,
26.47%, and 17.65% for SAGES, ASGE, and ESGE cri-
teria, respectively. Future studies should aim at develop-
ing more accurate criteria, and cost-effectiveness analysis
of predictive criteria versus confirmatory testing prior to
ERCP should also be undertaken.
CDL in our study is defined by presence of any 1 of the
following: filling defects on cholangiography, endoscopic
photodocumentation of CBDS, CBDS is documented by a
radiologist while MRCP or CBDS is visualized by the oper-
ating surgeon [14]. The abnormal LFTs were defined accord-
ing to our hospital laboratory thresholds: TB > 1.2 mg/dL,
alkaline phosphatase > 120 U/L, and aspartate transaminase
and alanine aminotransferase ≥ 35 U/L in female and ≥ 50
U/L in male. This approach was similar to the validation
study of ASGE criterion done by He et al. [8]. A patient
is diagnosed as ascending cholangitis when he/she pre-
sents with fever and epigastric pain or right upper quad-
rant pain, and has abnormal LFTs with evidence of biliary
tract obstruction on imaging [14]. The CBD sludge without
CBDS was considered as CDL in our study because they
have similar clinical significance [15]. According to our
study, the presence of CBD sludge was only 0.36% which
is in contrast to a previous study where the frequency of
CBD sludge was reported to be 14% [15]. This huge differ-
ence is likely due to documentation of only CBDS when a
patient had both CBD sludge and CBDS because it will have
no effect on risk stratification, and another reason could be
due to retrospective design resulting to exclusion of sub-
stantial number of patients. When a patient had documented
CBDS on MRCP but no CBDS were seen during therapeutic
procedures, we still considered the patient to have CDL as
it may have passed during the waiting period for interven-
tion. Previous studies have reported that about 21 to 73%
of stones may pass spontaneously [16]. When a patient had
multiple admissions or repeated laboratory tests, the data at
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first admission or the initial test were chosen for the analysis
to maintain homogeneity of the data.
Our study has some limitations. Firstly, it is a retrospec-
tive study design. However, the entire data were individually
reviewed and collected from a reliable electronic database of
our hospital. Secondly, we have to exclude a large number
of patients due to lack of confirmatory testing. In our center,
the diagnosis and management decisions are upon discretion
of the treating surgeon. Future prospective validation studies
with strict adherence to the above criteria may provide more
valid results.
Conclusions
In conclusion, we validated and confirmed that the current
SAGES, ASGE, and ESGE criteria have acceptable diagnos-
tic accuracy for CDL. The patients with visualized CBDS on
imaging have the highest risk for CDL.
Acknowledgements All the staff of the Department of Surgery, Surin
Hospital for providing critical guidance for this study.
Funding No external funding was received for this study.
Declarations
Disclosures Kinzang Wangchuk, M.D., and Pongsakorn Srichan, M.D.,
FRCST, have no conflict of interest or financial ties to disclose.
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