Validation and improvement of a proposed scoring system to detect retained common bile duct stones in gallstone pancreatitis

Surgery. 2015 Jun;157(6):1073-9. doi: 10.1016/j.surg.2015.01.005. Epub 2015 Feb 21.

Abstract

Background: In 2009, a study from our institution used retrospective data and multivariate analysis to identify 5 quantitative variables and their cutoffs that have a positive predictive value (PPV) for common bile duct (CBD) stones in gallstone pancreatitis. They also proposed a management protocol based on the scoring system. This prospective study sought to validate that scoring system.

Methods: From October 2009 to August 2013, patients with gallstone pancreatitis were enrolled in the study. Scores of 0-5 were determined at admission, with 1 point for each criterion met: CBD ≥ 9 mm, gamma glutamyltransferase ≥ 350 U/L, alkaline phosphatase ≥ 250 U/L, total bilirubin ≥ 3 mg/dL, and direct bilirubin ≥ 2 mg/dL. All CBDs were assessed using intraoperative cholangiogram, MR cholangiopancreatography (MRCP), or endoscopic retrograde cholangiopancreatography (ERCP).

Results: Of 84 patients, 16 had CBD stones. A score of 0 had negative predictive value (NPV) of 100% for CBD stones (P < .001). Scores of 1 and 2 had NPV of 81% and 83%, respectively. A score of 3 had NPV of 60%. A score of 4 had PPV of 67% (P = .002). A score of 5 had PPV of 100% (P < .001). The overall accuracy of the scoring system was 88%.

Conclusion: The scoring system is accurate in prediction of CBD stones in patients with gallstone pancreatitis. We propose that patients with 0 points undergo laparoscopic cholecystectomy, 1 and 2 points undergo laparoscopic cholecystectomy with intraoperative cholangiogram, 3 and 4 points undergo MRCP, and 5 points undergo ERCP as the first step in management for gallstone pancreatitis. The proposed protocol eliminated negative ERCPs.

Publication types

  • Comparative Study
  • Validation Study

MeSH terms

  • Academic Medical Centers
  • Adult
  • Aged
  • Cholangiopancreatography, Endoscopic Retrograde / methods
  • Cholecystectomy, Laparoscopic / adverse effects
  • Cholecystectomy, Laparoscopic / methods*
  • Clinical Protocols / standards*
  • Common Bile Duct / diagnostic imaging
  • Common Bile Duct / surgery
  • Evaluation Studies as Topic
  • Female
  • Follow-Up Studies
  • Gallstones / complications
  • Gallstones / diagnosis*
  • Gallstones / surgery*
  • Humans
  • Male
  • Middle Aged
  • Monitoring, Intraoperative / methods
  • Multivariate Analysis
  • New York City
  • Pancreatitis / complications
  • Pancreatitis / diagnosis*
  • Pancreatitis / surgery*
  • Postoperative Complications / diagnostic imaging
  • Postoperative Complications / surgery
  • Predictive Value of Tests
  • Quality Improvement
  • Retrospective Studies
  • Risk Assessment
  • Severity of Illness Index
  • Sphincterotomy, Endoscopic / adverse effects
  • Sphincterotomy, Endoscopic / methods
  • Treatment Outcome