Title: Is a Scoring System Valid for Detecting Common Bile Duct Stones in Gallstone Pancreatitis
Authors: Dr Sudhir M., Dr Shravan Kumar K R, Dr Amrit Preetam Panda, Dr Deepak Lal
DOI: https://dx.doi.org/10.18535/jmscr/v7i12.92
Abstract
Background: The passage of gallstones from the gallbladder through the common bile duct (CBD) into the duodenum has been implicated in the pathophysiology of acute Gall stone pancreatitis. Most stones in the CBD pass spontaneously; however, retained CBD stones cause persistent biliary obstruction and morbidity increase when obstruction is present for >48 hours.The scoring system and protocol proposed by a 2009 study simplifies the diagnosis and management of retained CBD stones in gallstone pancreatitis by using 5 variables obtained at admission. Special consideration must be given in the setting of a persistent CBD stone because it changes the management of the case; in addition to cholecystectomy, the CBD stone must be removed.
Methods: 40 patients who were admitted with Gallstone pancreatitis in kempegowda institute of medical sciences, Bangalore from December 2017 to August 2019 under department of general surgery. Patients were evaluated for presence of common bile duct (CBD) calculi using USG, MRCP, CECT and were appropriately referred for ERCP (Endoscopic retrograde cholangio Pancreatography) for extraction of CBD calculi.
Patients are given 1 of 6 possible scores (0–5). Initial admission laboratory values and ultrasonography results are used.
One point assigned for each of the following;
- a) CBD size - >=9 mm, (CBD-Common Bile Duct)
- b) GGT - >=350 U/L, (Gamma glutamyl transferase)
- c) AP - >=250 U/L, (Alkaline Phosphatase)
- d) TB - >=3 mg/dL, (Total Bilirubin)
- e) DB - >= 2 mg/dl (Direct Bilirubin)
Proposed Score Based Treatment
- a) 0- LAPAROSCOPIC CHOLECYSTECTOMY
- b) 1- LAPAROSCOPIC CHOLECYSTECTOMY
- c) 2- MRCP ASSESSMENT + LAPAROSCOPIC CHOLECYSTECTOMY
- d) 3 and 4 -MRCP ASSESSMENT + LAPAROSCOPIC CHOLECYSTECTOMY
- e) 5- ERCP
Results: Total study population consisted of 40 patients of which 13 patients had CBD stones and 27 patients didn’t have any CBD stones .Majority of the study population consisted of Females(65%) and major population group was aged between 51 -60 age group (including males and females 35%). Majority of the population group underwent laparoscopic cholecystectomy (36 patients) while 2 patients underwent Open CBD exploration and 2 patients underwent ERCP only during the study period. According to our scoring system overall negative predictive value (NPV) of the scoring system was 83.3% while overall positive predictive value (PPV) was 56.3% for the scoring system of which score 5 had 100% PPV. The overall accuracy of the scoring system was 72.5%.
Conclusion: The overall accuracy of the study is 72.5% using this scoring system. we propose the following for patients: those with score 0 or 1 undergo LC with follow up To rule out biliary obstruction or recurrent pancreatitis post-operatively; score 2 ,3 or 4 undergo MRCP assessment and score 5 should go directly to ERCP. Every patient is advised LC as a definitive treatment to prevent recurrence of Gall stone. Pancreatitis in same admission or for interval cholecystectomy. The proposed scoring system helps eliminate negative ERCPs and complications associated with ERCPs.
Keywords: Common bile duct stones, Gall stone Pancreatitis, Retained CBD stones, Laparoscopic cholecystectomy.
