Organization: British Society of Gastroenterology
Target Audience: Gastrointestinal endoscopists and surgeons
Background and Objective
The incidence of common
bile duct stones (CBDS) is estimated to be 5% to 10% among patients undergoing laparoscopic cholecystectomy for symptomatic cholelithiasis and 18% to 33% among patients with acute biliary pancreatitis. Endoscopic retrograde cholangiopancreatography (ERCP)
with stone extraction has been the first-line management strategy for CBDS. This British guideline updates evidence-based recommendations for CBDS management first published in 2008.
Use magnetic resonance cholangiopancreatography or endoscopic ultrasound, both highly recommended, in diagnosing CBDS in patients with intermediate probability of disease. The choice of test should be tailored to local
expertise, test availability, and patient suitability.
Perform ERCP using propofol sedation or general anesthesia.
To reduce risk for post-ERCP pancreatitis (PEP), assuming
no contraindications, administer rectal indomethacin 100 mg at the time of the procedure, and also insert a pancreatic stent if the patient has high risk for PEP.
Although endoscopic papillary balloon dilation in
the absence of prior biliary sphincterotomy is associated with higher risk for PEP, consider performing it in selected high-risk patients (e.g., coagulopathy); if performed, use an 8-mm balloon.
Consider use of
laparoscopic bile duct exploration (transductal or transcystic) for CBDS removal as it is associated with shorter length of stay compared with perioperative ERCP.
Perform cholecystectomy unless surgery risk is too
high, in which case consider biliary sphincterotomy and stone extraction or biliary stent as an alternative.
Offer laparoscopic cholecystectomy to all patients following biliary pancreatitis and operate within 2
weeks, preferably during the index admission.
In patients with biliary pancreatitis who have associated cholangitis or persistent obstruction, perform ERCP with stone extraction within 72 hours of presentation.