Suspected common bile duct stones: reduction of unnecessary ERCP by pre-procedural imaging and timing of ERCP

Christina J. Sperna Weiland*, Evelien C. Verschoor, Dutch Pancreatitis Study Grp, Alexander C. Poen, Xavier J. M. N. Smeets, Niels G. Venneman, Abha Bhalla, Ben J. M. Witteman, Hester C. Timmerhuis, Devica S. Umans, Jeanin E. van Hooft, Marco J. Bruno, P. Fockens, Robert C. Verdonk, Joost P. H. Drenth, Erwin J. M. van Geenen

*Corresponding author for this work

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Background Endoscopic retrograde cholangiopancreatography (ERCP) is the procedure of choice to remove sludge/stones from the common bile duct (CBD). In a small but clinically important proportion of patients with suspected choledocholithiasis ERCP is negative. This is undesirable because of ERCP associated morbidity. We aimed to map the diagnostic pathway leading up to ERCP and evaluate ERCP outcome.

Methods We established a prospective multicenter cohort of patients with suspected CBD stones. We assessed the determinants that were associated with CBD sludge or stone detection upon ERCP.

Results We established a cohort of 707 patients with suspected CBD sludge or stones (62% female, median age 59 years). ERCP was negative for CBD sludge or stones in 155 patients (22%). Patients with positive ERCPs frequently had pre-procedural endoscopic ultrasonography (EUS) or magnetic resonance cholangiopancreatography (MRCP) imaging (44% vs. 35%; P = 0.045). The likelihood of ERCP sludge and stones detection was higher when the time interval between EUS or MRCP and ERCP was less than 2 days (odds ratio 2.35; 95% CI 1.25-4.44; P = 0.008; number needed to harm 7.7).

Conclusions Even in the current era of society guidelines and use of advanced imaging CBD sludge or stones are absent in one out of five ERCPs performed for suspected CBD stones. The proportion of unnecessary ERCPs is lower in case of pre-procedural EUS or MRCP. A shorter time interval between EUS or MRCP increases the yield of ERCP for suspected CBD stones and should, therefore, preferably be performed within 2 days before ERCP.



Original languageEnglish
Number of pages9
JournalSurgical Endoscopy and Other Interventional Techniques
Publication statusE-pub ahead of print - 26 Sep 2022

Bibliographical note


The study was funded by the Netherlands Organisation
for Health Research and Development (ZonMw; Grant Number
837001506) and the Radboud university medical center. ZonMw had
no role in study design, data collection, data analysis, data interpretation, or writing of the report


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