The last 30 years have seen major developments in the management of gallstone-related disease, which in the United States alone costs over 6 billion dollars per annum to treat. Endoscopic retrograde cholangiopancreatography (ERCP) has become a widely available and routine procedure, whilst open cholecystectomy has largely been replaced by a laparoscopic approach, which may or may not include laparoscopic exploration of the common bile duct (LCBDE). In addition, new imaging techniques such as magnetic resonance cholangiography (MR) and endoscopic ultrasound (EUS) offer the opportunity to accurately visualise the biliary system without instrumentation of the ducts. As a consequence clinicians are now faced with a number of potentially valid options for managing patients with suspected CBDS. It is with this in mind that the following guidelines have been written.

/pdf/guidelines-on-the-management-of-common-bile-duct-stones-cbds-auly7w0tiu.pdf

Guidelines on the management of common bile duct stones (CBDS).

ESGE recommends offering stone extraction to all patients with common bile duct stones, symptomatic or not, who are fit enough to tolerate the intervention. Strong recommendation, low quality evidence. ESGE recommends liver function tests and abdominal ultrasonography as the initial diagnostic steps for suspected common bile duct stones. Combining these tests defines the probability of having common bile duct stones. Strong recommendation, moderate quality evidence. ESGE recommends endoscopic ultrasonography or magnetic resonance cholangiopancreatography to diagnose common bile duct stones in patients with persistent clinical suspicion but insufficient evidence of stones on abdominal ultrasonography. Strong recommendation, moderate quality evidence. ESGE recommends the following timing for biliary drainage, preferably endoscopic, in patients with acute cholangitis, classified according to the 2018 revision of the Tokyo Guidelines: – severe, as soon as possible and within 12 hours for patients with septic shock – moderate, within 48 – 72 hours – mild, elective. Strong recommendation, low quality evidence. ESGE recommends endoscopic placement of a temporary biliary plastic stent in patients with irretrievable biliary stones that warrant biliary drainage. Strong recommendation, moderate quality of evidence. ESGE recommends limited sphincterotomy combined with endoscopic papillary large-balloon dilation as the first-line approach to remove difficult common bile duct stones. Strong recommendation, high quality evidence. ESGE recommends the use of cholangioscopy-assisted intraluminal lithotripsy (electrohydraulic or laser) as an effective and safe treatment of difficult bile duct stones. Strong recommendation, moderate quality evidence. ESGE recommends performing a laparoscopic cholecystectomy within 2 weeks from ERCP for patients treated for choledocholithiasis to reduce the conversion rate and the risk of recurrent biliary events. Strong recommendation, moderate quality evidence.

/pdf/endoscopic-management-of-common-bile-duct-stones-european-1n4upif0zg.pdf

Endoscopic management of common bile duct stones: European Society of Gastrointestinal Endoscopy (ESGE) guideline

The role of endoscopy in the management of choledocholithiasis

Gallbladder stones (GBS) are found in up to 50% of patients receiving octreotide, but the reported prevalence of cholecystolithiasis in patients treated with octreotide is variable and little is known about gallstone incidence, composition, pathogenetic mechanisms, dissolvability, and primary prevention. Octreotide treatment apart, in industrialised societies most GBS are mixed in composition, cholesterol-rich (arbitrarily greater than 70% cholesterol by weight), radiolucent (70%), and, given a patent cystic duct (70%), dissolvable in bile rendered unsaturated in cholesterol by oral ursodeoxycholic (UDCA) +/- chenodeoxycholic (CDCA) acid treatment. They form when (1) GB bile becomes supersaturated with cholesterol (as the molar ratio of cholesterol to phospholipids in biliary vesicles approaches 1:1, the vesicles become unstable); (2) there is an imbalance between pro- and anti-nucleating factors, which favors cholesterol crystal precipitation; and (3) there is stasis within the GB as a result of altered motor function and/or excess mucus that traps the crystals. These changes may be associated with altered (4) biliary bile acid composition (more DCA and less CDCA than normal), and/or (5) phospholipid fatty acid composition (arachidonyl-rich lecithin acting as a substrate for mucosal prostaglandin synthesis which, in turn, may influence both gallbladder motility, and mucus glycoprotein synthesis and secretion). During octreotide treatment, meal-stimulated cholecystokinin (CCK) release is impaired leading to GB hypomotility, but little is known about the effects of octreotide on biliary cholesterol saturation, crystal nucleation time, mucus glycoprotein concentration, bile acid or phospholipid fatty acid composition. Most, but not all, reports suggest that the prevalence of GBS in octreotide-treated patients is considerably greater than that in age-, sex-, and weight-matched controls, but proof (by pre-treatment and on-treatment ultrasound) that the GBS were absent before, but developed during, therapy is not always available. Furthermore, there are few data on analysis of GBS composition in patients developing stones during treatment, although initial reports suggest that octreotide-associated GBS are also radiolucent, cholesterol-rich, and dissolve with oral bile acid treatment. Maximum GBS attenuation values, measured in Hounsfield Units (HU) by localized computerized tomography scanning of the GB, predict stone composition and dissolvability: GBS with scores of less than 100 HU are cholesterol-rich and dissolve well with oral bile acid treatment. However, preliminary results in 11 acromegalic patients treated with 200 to 600 micrograms octreotide/d for 29 to 68 months show that the HU scores range from 23 to 490 (mean +/- SEM, 116 +/- 41), suggesting that at least four of these 11 patients have non-cholesterol stones.(ABSTRACT TRUNCATED AT 400 WORDS)

Gallstones during octreotide therapy.

https://aasldpubs.onlinelibrary.wiley.com/doi/pdf/10.1002/hep.510280103

Hepatic bile versus gallbladder bile: A comparison of protein and lipid concentration and composition in cholesterol gallstone patients

The concentrations of total protein, mucus glycoprotein, cyclic-AMP, and apolipoproteins A-I, A-II, and B were determined in the gallbladder bile of patients with cholesterol gallbladder stones and in stone-free controls. The total protein content was significantly increased in gallstone patients (2.03 ± 0.6 versus 1.31 ± 0.67 mg/ ml; p < 0.05), as was the mucus glycoprotein concentration (380 ± 88.5 versus 128 ± 57.2 ug/ml; p < 0.05). The cyclic-AMP concentration in the gallbladder fluid was increased up to 91 ± 20 pmol/100 ul in the gallstone subjects, as compared with 46 ± 26 pmol/100 ul (p < 0.01) in stone-free controls. Cyclic-AMP concentrations correlated positively with the glycoprotein content of the bile in cholesterol gallstone patients (r = 0.66; p <0.05). The apolipoprotein concentrations were determined by the radial immundiffusion technique. The corresponding values for patients with stones and controls were 7.5 ± 0.8 verus 3.0 + 0.8 for Apo A-I (p < 0.025), 10.4 ±0.6 versus 6.3 ± 1.3 for Ap...

Total biliary protein, mucus glycoproteins, cyclic-AMP, and apolipoproteins in the gallbladder bile of patients with cholesterol stones and stone-free controls.

The effect of ursodeoxycholic acid on recurrence prevention of choledochal calculi after endoscopic sphincterotomy (EPT) was evaluated in 46 patients, whose bile duct stones had been removed endoscopically. 22 patients received 500 mg of ursodeoxycholic acid once a day, 24 patients received placebo. 1 recurrent stone could be detected in the ursodeoxycholic acid treated group 19 months after EPT, whereas 4 recurrent stones occurred in the placebo group about 16 months after EPT. Cholesterol saturation index decreased significantly by the ursodeoxycholic acid treatment 12 and 24 months after EPT (0.93 +/- 0.17 vs. 0.69 +/- 0.12 vs. 0.72 +/- 0.07). The nucleation time increased statistically significant from 9.0 days to 20.4 (12 months) and 17.7 (24 months) days, respectively. Obviously, pharmacological effects of ursodeoxycholic acid exist which modify important processes in the gallstone's pathogenesis.

Preventing the recurrence of common bile duct calculi following endoscopic papillotomy with ursodeoxycholic acid

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Total biliary protein, mucus glycoproteins, cyclic-AMP, and apolipoproteins in the gallbladder bile of patients with cholesterol stones and stone-free controls.

Preventing the recurrence of common bile duct calculi following endoscopic papillotomy with ursodeoxycholic acid