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Guidelines on the Management of Common Bile Duct Stones Downloaded from http://gut.bmj.com/ on May 23, 2017 - Published by group.bmj.com Guidelines Updated guideline on the management of common bile duct stones (CBDS) Earl Williams,1 Ian Beckingham,2 Ghassan El Sayed,1 Kurinchi Gurusamy,3 Richard Sturgess,4 George Webster,5 Tudor Young6 1Bournemouth Digestive ABSTRACT suspicion remains high. (Low-quality evidence; Diseases Centre, Royal Common bile duct stones (CBDS) are estimated to be strong recommendation) Bournemouth and Christchurch – NHS Hospital Trust, present in 10 20% of individuals with symptomatic Bournemouth, UK gallstones. They can result in a number of health New 2016 2HPB Service, Nottingham problems, including pain, jaundice, infection and acute Magnetic resonance cholangiopancreatography University Hospitals NHS Trust, pancreatitis. A variety of imaging modalities can be (MRCP) and endoscopic ultrasound (EUS) are both Nottingham, UK 3 employed to identify the condition, while management recommended as highly accurate tests for identifying Department of Surgery, fi University College London of con rmed cases of CBDS may involve endoscopic CBDS among patients with an intermediate probabil- Medical School, London, UK retrograde cholangiopancreatography, surgery and ity of disease. MRCP predominates in this role, with 4Aintree Digestive Diseases radiological methods of stone extraction. Clinicians are choice between the two modalities determined by Unit, Aintree University Hospital therefore confronted with a number of potentially valid individual suitability, availability of the relevant test, Liverpool, Liverpool, UK 5Department of options to diagnose and treat individuals with suspected local expertise and patient acceptability. (Moderate Hepatopancreatobiliary CBDS. The British Society of Gastroenterology first quality evidence; strong recommendation) Medicine, University College published a guideline on the management of CBDS in Hospital, London, UK 2008. Since then a number of developments in New 2016 6Department of Radiology, The Princess of Wales Hospital, management have occurred along with further systematic It is suggested that patients with suspected CBDS Bridgend, UK reviews of the available evidence. The following who have not been previously investigated should recommendations reflect these changes and provide undergo USS and LFTs. For patients with an inter- Correspondence to updated guidance to healthcare professionals who are mediate probability of stones, MRCP or EUS is Dr Earl Williams, Digestive involved in the care of adult patients with suspected or recommended as a next step unless the patient is Diseases Centre, Royal proven CBDS. It is not a protocol and the proceeding directly to cholecystectomy supplemen- Bournemouth Hospital, Castle ted by intraoperative cholangiography (IOC) or Lane East, Bournemouth BH7 recommendations contained within should not replace 7DW, UK; earl.williams@rbch. individual clinical judgement. laparoscopic ultrasound (LUS). Endoscopic retro- nhs.uk grade cholangiopancreatography (ERCP) should be reserved for patients in whom preceding assessment Received 25 May 2016 SUMMARY OF RECOMMENDATIONS indicates a need for endoscopic therapy. (Low- Revised 8 December 2016 Where recommendations from the 2008 guide- quality evidence; weak recommendation) Accepted 15 December 2016 1 Published Online First lines are obsolete, they are omitted. Where recom- 25 January 2017 mendations are prefaced by ‘2008’ there has been Endoscopic management of CBDS no new evidence found since the last guideline and New 2016 no change in the recommendation; ‘2008, It is suggested that the British Society of amended 2016’ indicates that while no new evi- Gastroenterology (BSG) national standards frame- dence has been found since the last guideline there work for ERCP is implemented by service providers. has been a change in wording that effects the (Very low-quality evidence; weak recommendation) meaning of the recommendation; ‘2016’ indicates that new evidence has been found and no change New 2016 in the recommendation is necessary; ‘New 2016’ For selected patients, tolerability and likelihood of indicates that new evidence has resulted in a new therapeutic success is higher if ERCP is performed or amended recommendation. with propofol sedation or general anaesthesia. It is recommended that hospitals looking after patients General principles in management of common with CBDS should have ready and prompt access bile duct stones to anaesthesia supported ERCP. This can be an New 2016 on-site service or provided by another ERCP unit It is recommended that patients diagnosed with as part of a clinical network. (Low-quality evi- common bile duct stones (CBDS) are offered stone dence; strong recommendation) extraction if possible. Evidence of benefit is greatest for symptomatic patients. (Low-quality evidence; 2008 strong recommendation) It is suggested that patients should be managed in accordance with the BSG guidelines on antibiotic Identifying individuals with CBDS prophylaxis during endoscopy. (Very low-quality New 2016 evidence; weak recommendation) Trans-abdominal ultrasound scanning (USS) and To cite: Williams E, liver function tests (LFTs) are recommended for New 2016 Beckingham I, El Sayed G, patients with suspected CBDS. Normal results do To reduce the risk of post-ERCP pancreatitis (PEP) et al. Gut 2017;66:765–782. not preclude further investigation if clinical it is recommended that diclofenac or indomethacin Williams E, et al. Gut 2017;66:765–782. doi:10.1136/gutjnl-2016-312317 765 Downloaded from http://gut.bmj.com/ on May 23, 2017 - Published by group.bmj.com Guidelines (at a dose of 100 mg) should be administered rectally at the 2016 time of ERCP to all patients who do not have a contraindication It is recommended that, in patients undergoing laparoscopic to non-steroidal anti-inflammatory drugs (NSAIDs). cholecystectomy, transcystic or transductal laparoscopic bile (Moderate-quality evidence; strong recommendation) duct exploration (LBDE) is an appropriate technique for CBDS removal. There is no evidence of a difference in efficacy, mortal- New 2016 ity or morbidity when LBDE is compared with perioperative In patients with a high risk of PEP arising from repeated pancre- ERCP, although LBDE is associated with a shorter hospital stay. atic duct cannulation, insertion of a pancreatic stent is suggested It is recommended that the two approaches are considered in addition to administration of rectal NSAID. (Moderate- equally valid treatment options. (High-quality evidence; strong quality evidence; weak recommendation) recommendation) 2008, amended 2016 New 2016 It is recommended that patients undergoing biliary sphincterot- It is suggested that training of surgeons in LBDE is to be encour- omy for ductal stones have a full blood count (FBC) and inter- aged in order to decrease the number of interventions required to national normalised ratio or prothrombin time (INR/PT) manage CBDS. (Low-quality evidence; weak recommendation) performed prior to their ERCP.If deranged clotting or thrombo- fi cytopenia is identi ed, subsequent management should conform ‘ fi ’ to locally agreed guidelines. (Low-quality evidence; strong Management of dif cult ductal stones recommendation) New 2016 Laparoscopic duct exploration and ERCP (supplemented by New 2016 EPBD with prior sphincterotomy, mechanical lithotripsy or cho- It is recommended that ERCP patients taking warfarin, antipla- langioscopy where necessary) are highly successful in removing telet treatment or a direct oral anticoagulant (DOAC) should be CBDS. It is recommended that percutaneous radiological stone managed in accordance with the combined BSG and European extraction and open duct exploration should be reserved for the Society of Gastrointestinal Endoscopy (ESGE) guidelines for small number of patients in whom these techniques fail or are patients undergoing endoscopy. (Low-quality evidence; strong not possible. (Low-quality evidence; strong recommendation) recommendation) New 2016 2008, amended 2016 When endoscopic cannulation of the bile duct is not possible Competency in access papillotomy is suggested for all endosco- with standard techniques including access papillotomy, it is pists who perform ERCP. Training and subsequent mentorship recommended that percutaneous or EUS-guided procedures can should facilitate this. (Very low-quality evidence; weak be considered as a means of facilitating subsequent ERCP. (Low- recommendation) quality evidence; strong recommendation) New 2016 2016 As an adjunct to biliary sphincterotomy, endoscopic papillary It is important that endoscopists ensure adequate biliary drain- balloon dilation (EPBD) is recommended as a technique to age is achieved in patients with CBDS that have not been facilitate removal of large CBDS. (High-quality evidence; strong extracted. The short-term use of a biliary stent followed by recommendation) further endoscopy or surgery is recommended. (Moderate- quality evidence; strong recommendation) New 2016 EPBD without prior biliary sphincterotomy is associated with an 2016 increased risk of PEP but may be considered as an alternative to The use of a biliary stent as sole treatment for CBDS should be biliary sphincterotomy in selected patients, such as those with restricted to a selected group of patients with limited life expect- an uncorrected coagulopathy or difficult biliary access due to ancy and/or prohibitive surgical risk. (Moderate-quality evi- altered anatomy. If EPBD is performed without prior biliary dence; strong recommendation)
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