TheroleofendoscopyintheevaluationofsuspectedThisisoneofaseriesofstatem - PDF document

TheroleofendoscopyintheevaluationofsuspectedThisisoneofaseriesofstatementsdiscussingtheuseofGIendoscopyincommonclinicalsituations.TheStan-dardsofPracticeCommitteeoftheAmericanSocietyforGastrointestinalEndoscopypreparedthistext.Inprepar-ingthisguideline,asearchofthemedicalliteraturewasperformedbyusingPubMed.AdditionalreferenceswereobtainedfromthebibliographiesoftheidentiÞedarticlesandfromrecommendationsofexpertconsultants.Whenfewornodataexistfromwell-designedprospectivetrials, Copyright2010bytheAmericanSocietyforGastrointestinalEndoscopy0016-5107/$36.00doi:10.1016/j.gie.2009.09.041 www.giejournal.orgVolume71,No.1:2010GASTROINTESTINALENDOSCOPY Thenormalbileductdiameteris3to6mm,24-26andmilddilationrelatedtoadvancingagehasbeenreported.Bili-arydilationgreaterthan8mminapatientwithanintactgallbladderisusuallyindicativeofbiliaryobstruction.Also,thesonographiccharacterizationofgallbladderstonesharborssomepredictivevalueforcholedocholithiasis,withmultiplesmall(5mm)stonesposinga4-foldhigherriskofmigrationintotheductasopposedtolargerand/orsol-itarystones.Giventherelativelylowprevalence(5%-10%)ofcholedocholithiasisinpatientswithsymptomaticchole-lithiasis,anormalbileductUShasa95%to96%negativepredictivevalue.12,28Thus,althoughnosinglevariableconsistentlystronglypredictscholedocholithiasisinpatientswithsymptomaticcholelithiasis,manyinvestigatorshavenotedthattheprobabilityofaCBDstoneishigherinthepresenceofmultipleabnormalprognosticsigns.Asaresult,anumberofdifferentprognosticscores,formulas,andalgorithmshavebeendevisedtohelppredicttheprobabil-ityofcholedocholithiasis.13,14,29,31,32Althoughthereisnosingleacceptedscoringsystem,byusingfactorssuchasage,livertestresults,andUSÞndings,patientscangener-allybecategorizedintolow(10%),intermediate(10%-50%),andhigh(50%)probabilityofcholedocholithiasisTable2).ACBDstoneseenonUSisthemostreliablepredictorofcholedocholithiasisatsubsequentendoscopicretrogradecholangiography(ERC)orsurgery.speciÞcityofUSforCBDstonesisveryhigh,withocca-sionaldiscrepanciesattributedtointervalstonemigrationorfalselypositiveUSÞndings.Otherwise,themostpredic-tivevariablesseemtobecholangitis,abilirubinlevelhigherthan1.7mg/dL,andadilatedCBDonUS.Thepres-enceof2ormoreofthesevariablesresultsinahighprob-abilityofaCBDstone.Advancedage(olderthan55years),elevationofaliverbiochemicaltestresultotherthanbilirubin,andpancreatitisarelessrobustpredictorsforcholedocholithiasis.Conversely,nonjaundicedpatientswithanormalbileductonUShavealowproba-bility(5%)ofcholedocholithiasis.ARISK-STRATIFIEDDIAGNOSTICAPPROACHTOPATIENTSWITHSYMPTOMATICCHOLELITHIASISAproposedstrategytoassignriskofcholedocholithia-sisbasedonclinicalpredictorsevidentafterinitialdiag-nosticevaluationispresentedinTable2.Thistablesummarizestherelativeimportanceofcommonclinicalpredictorsforcholedocholithiasisbasedontheavailable TABLE1.GRADEsystemforratingthequalityof evidenceforguidelines QualityofDefinitionSymbolHighqualityFurtherresearchisveryunlikelytochangeourconfidenceintheestimateofeffect.ModeratequalityFurtherresearchislikelytohaveanimportantimpactonourconfidenceintheestimateofeffectandmaychangetheLowqualityFurtherresearchisverylikelytohaveanimportantimpactonourconfidenceintheestimateofeffectandislikelytochangetheVerylowqualityAnyestimateofeffectisveryuncertain.Weakerrecommendationsareindicatedbyphrasessuchas‘‘wesuggest,’’whereasstrongerrecommendationsaretypicallystatedas‘‘werecommend.’’AdaptedfromGuyattetal. TABLE2.Aproposedstrategytoassignriskof choledocholithiasisinpatientswithsymptomatic cholelithiasisbasedonclinicalpredictors PredictorsofcholedocholithiasisVerystrongCBDstoneontransabdominalUSClinicalascendingcholangitis4mg/dLDilatedCBDonUS(6mmwithgallbladderinsitu)Bilirubinlevel1.8-4mg/dLAbnormalliverbiochemicaltestotherthanbilirubinAgeolderthan55yClinicalgallstonepancreatitisAssigningalikelihoodofcholedocholithiasisbasedonclinicalpredictorsPresenceofanyverystrongpredictorHighPresenceofbothstrongpredictorsHighNopredictorspresentLowAllotherpatientsIntermediate,Commonbileduct. Theroleofendoscopyintheevaluationofsuspectedcholedocholithiasis GASTROINTESTINALENDOSCOPYVolume71,No.1:2010www.giejournal.org literature;however,itisnotavalidatedclinicaldecisionaid.Asuggestedmanagementalgorithmforpatientswithsymptomaticcholelithiasis,basedonwhethertheyareatlow,intermediate,orhighprobabilityofcholedo-cholithiasis,ispresentedinFigure1LowriskofcholedocholithiasisPatientswithsymptomaticcholelithiasiswhoarecandi-datesforsurgeryandhavealowprobabilityofcholedo-cholithiasis(10%)shouldundergocholecystectomy;nofurtherevaluationisrecommendedbecausethecostandrisksofadditionalpreoperativebiliaryevaluationarenotjustiÞedbythelowprobabilityofaCBDstone.Whetherroutineintraoperativecholangiography(IOC)orlaparoscopicUSshouldbeperformedatlaparoscopiccholecystectomy,forpurposesofbothdeÞningthebiliaryanatomyandforscreeningforCBDstones,isanareaofcontroversyinthesurgicalliterature.IntermediateriskofcholedocholithiasisPatientsatintermediateprobabilityofcholedocholithia-sis(10%-50%)afterinitialevaluationbeneÞtfromaddi-tionalbiliaryimagingtofurthertriagetheneedforductalstoneclearance.FailuretoidentifyCBDstonescanresultinrecurrentsymptoms,cholangitis,andABP.Optionsforevaluationofthesepatientsincludeendoscopicultrasound(EUS),magneticresonancecholangiography(MRC),preoperativeERC,andIOCorlaparoscopicUStofacilitateeitherremovalatsurgeryorpostoperativeERC.HighriskofcholedocholithiasisPatientsathighprobabilityofCBDstones(requirefurtherevaluationofthebileduct;becauseofthefrequentneedfortherapy,typicallypreoperativeERCorop-erativecholangiographyareundertaken.Intheeraofopencholecystectomy,therewasnoadvantagefoundforpreop-erativeERCoveroperativecholangiographyandcommonductexplorationinrandomized,controlledtrials. Figure1.Asuggestedmanagementalgorithmforpatientswithsymptomaticcholelithiasisbasedonthedegreeofprobabilityforcholedocholithiasis.ModiÞedfromTseetal. Theroleofendoscopyintheevaluationofsuspectedcholedocholithiasis www.giejournal.orgVolume71,No.1:2010GASTROINTESTINALENDOSCOPY However,opencholecystectomyisnowinfrequentlyperformedgiventheattenuatedmorbidityandshorterhos-pitalstaysassociatedwithlaparoscopiccholecystectomy.Tworandomized,controlledtrialscompared2-stageman-agement(preoperativeERCfollowedbylaparoscopiccho-lecystectomy)withanall-surgicalapproachoflaparoscopicIOCandtranscysticstoneremovalorlaparoscopiccholedo-chotomyforpatientsathighriskofcholedocholithiasis.Inthesestudies,therewasnodifferenceinmorbidity,mor-tality,orprimaryductalclearancerates(88%)betweenthe2arms.OtherpotentialoptionsincludeintraoperativeorpostoperativeERCforpatientswithpositiveIOCÞndings;laparoscopicantegradeplacementofatranspapillarystenttoensurebiliaryaccessatpostoperativeERCmayalsobeconsidered.Amorerobustdiscussionofoperativeversusendoscopicmanagementofcholedocholithiasisinpatientsundergoingcholecystectomyisbeyondthescopeofthisguideline.However,CBDstonedetectionandsubsequentmanagementareinseparablylinked,andmanyofthetech-niquesusedforbiliaryevaluationandCBDstoneremovalareconsiderablyoperatordependent.Thus,thebeststrat-egiesfortheevaluationandmanagementofcholedocholi-thiasisinpatientswithsymptomaticcholelithiasiswillbeheavilypredicatedonlocalexpertiseandavailabletechnology.NonendoscopicbiliaryimagingmodalitiesCT:Conventional(nonhelical)CThashistoricallydem-onstratedbettersensitivityforcholedocholithiasisthantransabdominalUSwhencompositediagnosticcriteriaareused(eg,theinclusionofindirectsignssuchasductaldilation),althoughdirectvisualizationofstoneshasnotexceeded75%.HelicalCThasshownimprovedperfor-manceoverconventionalCTforcholedocholithiasis,with65%to88%sensitivityand73%to97%speciÞcity.46-49ExpenseandradiationexposurehavelimitedtheuseofCTasaÞrst-linediagnostictestforcholedocholithiasis,butinmanyinstances,abdominalCTscansareorderedintheemergencydepartmentsettingtoevaluateandexcludecompetingpotentialdiagnosesthatmayhavesim-ilarpresentations.MRC:MRChas85%to92%sensitivityand93%to97%speciÞcityforcholedocholithiasisdetection,asassessedin2recentsystematicreviews.However,thesensitivityofMRCseemstodiminishinthesettingofsmall6mm)stonesandhasbeenreportedas33%to71%inthisclinicalsubset.CTcholangiography:CTcholangiographyisper-formedbyusinghelicalCTinconjunctionwithadedicatedcholegraphiciodinatedcontrastagentthatistakenupbytheliverandexcretedintothebile.Althoughitsperfor-mancecharacteristicsforcholedocholithiasisdetectionaresimilartothoseofMRC,concernsregardingthetoxicityofavailablecholegraphicagentsandsigniÞcantradiationdosehavelimitedtheclinicaladoptionofthisimagingmodality.Intraoperativeßuorocholangiographymaybeperformedbyinsertionofsmallcatheterintoacysticductotomyorviathegallbladder(cholecystocholangiogra-phy)andinjectionofiodinatedcontrastdyewithreal-timeßuoroscopicinterpretationbythesurgeon.IOCcanbesuccessfullycompletedin88%to100%ofpatients,hasareportedsensitivityof59%to100%andspeciÞcityof93%to100%forcholedocholithiasis,andtypicallyrequiresbetween10and17minutestocompleteduringalaparo-scopiccholecystectomy.LaparoscopicUS:LaparoscopicUStransducersareavailableinavarietyofviewingarrays,mayberigidorßex-ible,andÞtthroughaconventionallaparoscopictrocar.LaparoscopicUSoftheextrahepaticbileductcanbesuc-cessfullycompletedin88%to100%ofpatientsandcanbeperformedin4to10minutes,withareportedsensitivityof71%to100%andspeciÞcityof96%to100%.Laparo-scopicUShasareportedlylongerlearningcurvethandoesIOC.EndoscopicbiliaryimagingmodalitiesEUScombinesendoscopicvisualizationwith2-dimensionalUSandiswellsuitedforbiliaryimaginggiventhecloseproximityoftheextrahepaticbileducttotheproximalduodenum.Radialarrayechoendoscopesmorefrequentlyallowelongatedviewsofthebileductandarethuspreferredbymanyendosonographers;however,theperformanceoflineararrayinstrumentsforcholedocholithiasisisalsoexcellent,withseriesreportingasensitivityof93%to97%.Twometa-analyses,eachcomposedofmorethan25trialsandmorethan2500pa-tients,reportedan89%to94%sensitivityand94%to95%speciÞcityofEUSfordetectingcholedocholithiasis,withERC,IOC,orsurgicalexplorationusedascriterionstan-dards.EUSremainshighlysensitiveforstonessmallerthan5mm,anditsperformancedoesnotseemadverselyaffectedbydecreasingstonesize.Excludingexamina-tionsforesophagealcancerstaging,complicationswithdiagnosticEUSarerare(0.1%-0.3%).BecausetheriskofadverseeventsishigherwithERCthanwithnoninvasivebiliaryimagingstudiesorEUS,theuseofERCasadiagnosticmodalityisbestsuitedforthosepatientsathighriskofcholedocholithiasisbecausetheyaremostlikelytobeneÞtfromthetherapeuticcapa-bilityofERC.ERChastraditionallyservedasacriterionstandardforcholedocholithiasisdetection;thus,datare-gardingitsoperatingcharacteristicsarelimited.However,thesensitivityofERCwithcholangiographyalonehasbeenreportedas89%to93%withaspeciÞcityof100%instudiesthatusedsubsequentbiliarysphincterotomyandductsweepingwithballoons/basketsasthecriterionFalse-negativeERCÞndingsforcholedocho-lithiasistypicallyoccurinthesettingofsmallstonesinadilatedduct.TherisksofERCincludepancreatitis(1.3%-6.7%),infection(0.6%-5.0%),hemorrhage(0.3%-2.0%),and Theroleofendoscopyintheevaluationofsuspectedcholedocholithiasis GASTROINTESTINALENDOSCOPYVolume71,No.1:2010www.giejournal.org perforation(0.1%-1.1%)inprospectiveseriesofunse-lectedpatients.However,severalpatientvariables(eg,youngage,femalesex)havebeenidentiÞedthatserveasriskfactorsforpancreatitis;similarly,coagulopathyincreasesbleedingriskandimmunosuppressionincreasestheriskofinfectionatERC.Thus,riskestimatesmustbeindividualizedtothepatient.ERC-associatedtechnologies:Small-caliber,high-frequency(12-30MHz)wire-guidedintraductalUS(IDUS)probescanbepassedthroughtheinstrumentchannelofaduodenoscopeandintothebileductwithoutaprevioussphincterotomyinnearly100%ofcases.IDUShasdemonstratedexcellentsensitivity(97%-100%)forcholedocholithiasis,andsomestudieshaveshownmodestlyimprovedaccuracyofERCwithIDUSforstonedetectioncomparedwithcholangiographyalone.ever,theclinicalimpactofthehighsensitivityofIDUSforcholedocholithiasisisuncertainbecausestonesmissedbyERCthataredetectedbyIDUStendtobesmall4mm)andofunclearsigniÞcance.ConventionalÔÔmother-daughterÕÕornewersingle-oper-atorcholangioscopysystemsaremostoftenusedinthediagnosisofindeterminatebiliarystricturesandasanadjunctinthemanagementofcomplicatedstonedisease,butmayhavearoleinbiliarystonedetectioninlimitedsettings.AdherentorimpactedstonesmaybedifÞculttodifferentiatefromcomplexstricturesorbiliarypolyps,anddirectvisualizationhasbeenvaluableincharacterizingtheseindeterminateÞllingdefects.Othershavere-portedapotentialroleforcholangioscopyinconÞrmingductalclearanceinpatientsafterstoneextraction.AlthoughtheyarepotentiallyusefulinspeciÞcclinicalset-tings,giventheadditionaltimeandexpenseincurredbyIDUSandcholangioscopy,theiroverallroleinthediagno-sisofcholedocholithiasisremainslimited.EUS-directedERCGiventhehighermorbidityofERCcomparedwithEUS,severalinvestigatorsrecentlyevaluatedsequentialEUSandERCinpatientswithsuspectedcholedocholithiasisinanefforttobettertriagepatientsinneedoftreat-These4trialsrandomizedpatientsatintermedi-atetohighriskforcholedocholithiasistoanEUS-ÞrststrategyversusanERC-Þrststrategy.PatientsfoundtohaveCBDstonesatEUSunderwentsubsequenttherapeu-ticERC,whichwasperformedinthesamesettingin3ofthe4trials.Acrossthetrials,27%to40%ofpatientsrandomizedtoEUSwerefoundtohaveCBDstones,andthenegativepredictivevalueofEUSseemedtoberobust,withonly0%to4%ofpatientswithnormalEUSÞndingsreturningwithpancreaticobiliarysymptomsin1to2yearsoffollow-up.Thus,thissequentialapproachinthesestud-ieseliminatedtheneedfor60%to73%ofERCanditsattendantrisk.TherewaseitherlessmorbidityoratrendtowardlessmorbidityassociatedwiththeEUS-Þrststrat-egyacrossallstudies.AnEUS-guideddiagnosticstrategyalsoseemstobecost-effectiveformanypatientswithsuspectedcholedo-cholithiasis.InacostanalysisassociatedwithaprospectivetrialofEUSforsuspectedcholedocholithiasisinmorethan450patients,anEUS-Þrststrategywascost-effectiveforpatientswithanestimatedlikelihoodofCBDstonesoflessthan61%,withtheERC-Þrststrategyprovingthedominantstrategyforpatientsathigherrisk.Similarly,adecisionanalysisassessingtherolesofIOC,ERC,andEUSinpatientsundergoinglaparoscopiccholecystectomyfoundEUStobecost-effectivewhentheestimatedriskofCBDstoneswas11%to55%.Inbothofthesecostanal-yses,EUSandsubsequenttherapeuticERCwereper-formedonseparatedays;proceduresperformedintandemwithasinglesedationmayyieldevengreatersavings.TheroleofendoscopyforsuspectedcholedocholithiasisinthepostcholecystectomypatientCholedocholithiasisaftercholecystectomymayresultfromeitheramigratedgallbladderstonenotdetectedintheperioperativeperiodorastoneformingdenovointhecommonbileduct.Diagnosticconsiderationsareslightlydifferentinthesepatientsthaninthosewithagall-bladderinsitu.Althoughpatientspresentingwithpain,abnormalliverbiochemicaltests,jaundice,orfevermayhavecholedocholithiasis,alternativeprocessessuchasbileleak,iatrogenicbiliarystricture,andbiliary-typesphincterofOddidysfunctionareadditionalpossibilitiesinthepostcholecystectomypatient.Generally,theinitialevaluationofthesepatientsshouldincludeserumliverbiochemicaltestsandatransabdominalUS,mirroringtheapproachtotheprecholecystectomypatientwithsymptomaticcholelithiasis.However,dilationofthecommonbileductaftercholecystectomyhasbeenreported,sousinga6-mmcutofffornormalislikelynotappropriateforthispopulation.Also,somepatientsreportingpostcholecystectomypainmayhavechronicabdominalpainunrelatedtotheirbiliarytree,andthusunresolvedbycholecystectomy.Inthesepatients,useofnarcoticanalgesicsisnotuncommon,andbiliarydilationrelatedtonarcoticusehasalsobeenreported.Dataregardingtheevaluationforcholedocholithiasisinpatientswhohaveundergonecholecystectomyarelim-ited.However,postcholecystectomypatientswithnormalliverbiochemicaltestresultsandnormalUSÞndingsareveryunlikelytohavecholedocholithiasis.Inpostchole-cystectomypatientsreferredforERCbecauseofsuspectedcholedocholithiasisafterinitialevaluation,theincidenceofcholedocholithiasisis33%to43%.BothEUSandMRChavebeenshowntobehighlyaccurateforde-tectingcholedocholithiasisinthispatientsubset,aswellasprovidingalternativediagnosesinmanycases.Assuch,ERC,EUS,andMRCmayallbeconsideredinthediagnos-ticevaluationofpostcholecystectomypatientswheninitial Theroleofendoscopyintheevaluationofsuspectedcholedocholithiasis www.giejournal.orgVolume71,No.1:2010GASTROINTESTINALENDOSCOPY laboratoryandUSdataareabnormalyetnondiagnostic.However,giventhattheultimateincidenceofcholedo-cholithiasisisstilllessthan50%inthispopulation,EUSandMRCmaybepreferabletoERCinthissetting,partic-ularlygiventheirattenuatedmorbiditycomparedwithTheroleofendoscopyforsuspectedcholedocholithiasisinpatientswithgallstoneTheapproachtosuspectedcholedocholithiasisinpatientswithABPmaydifferfrompatientswithsymptom-aticcholelithiasisalone.Clinicalinvestigationshavedem-onstratedacorrelationbetweenthepresenceofpersistentCBDstonesandtheseverityofABP,particularlywhenbiliopancreaticobstructionispresent.Identify-ingpatientsmostlikelytobeneÞtfromearlydetectionandtreatmentofretainedCBDstonesinABPhasbeenanareaofcontroversy,however.Threerandomized,controlledtrialsfoundatrendtowardbeneÞtinpatientswithsuspectedABPwhowererandomizedtoearlyERC(within24-72hoursfrompresentation)withbiliarysphincterotomyversusconservativemanagement.Inthesetrials,thesubgroupswithpancreatitispredictedtobesevere(byRansonorGlasgowscoring)whounderwentearlyERChadsigniÞcantreductionsinmorbidityandmortality.Thesestudiesincludedpatientswithclinicalevidenceofbiliaryobstructionandcholangitis,andanalternativeinterpretationofthesedataisthatpatientswithpersistentbiliopancreaticobstruction,ratherthanthosewithpredictedsevereABP,beneÞtfromearlyendoscopicassessmentandintervention.Accordingly,arandomized,controlledtrialofearlyERCversusconservativemanage-mentinABPthatexcludedpatientswithabilirubinlevelgreaterthan5mg/dLfoundnobeneÞtinmorbidityandmortalityinpatientswithpredictedsevereABPwhounderwentearlyERC.Arecentmeta-analysisofearlyERCversusconservativecareinpatientswithABPthatexcludedpatientswithcholangitisalsofoundnobeneÞtinmorbidityandmortalityinpatientswithpredictedsevereABPwhounderwentearlyERC.Tworandom-ized,controlledtrialsthatsoughttoselectpatientswithABPwithpersistentbiliaryobstruction,butnotcholangi-tis,forearlyERCversusconservativecarewereconßictingintheiroutcomes,althoughtrialprotocolsdiffered.Insummary,intheabsenceofclearevidenceofaretainedstone,theredoesnotseemtobearoleforearlyERCintheevaluationandmanagementofpatientswithmildABP.Conversely,inpatientswithABPandconcomitantcholangitis,earlyERCisstronglyrecommendedgiventheobservedbeneÞtsinmorbidityandmortality.DataareconßictingastothebeneÞtofearlyERCinpatientswithpredictedsevereABPorinABPwithclinicalevidenceofbiliaryobstructionwhenacutecholangitisisabsent.AcutepancreatitismaycauseduodenalandpancreaticedemathatcouldtheoreticallyhinderEUSandimpairsonographicvisualizationofsmallstonesinthedistalCBD.However,inseveralstudiesofacutepan-creatitis,EUSprovidedanassessmentofthebileductinalmostallpatientswhilemaintainingahighlevelofaccu-racyforCBDstones(97%-100%).GiventherisksanduncertainbeneÞtassociatedwithERCinpatientswithABPandthemodestprevalenceofcholedocholithia-sisinABP(18%-33%),investigatorshavealsotargetedthisscenarioforEUS-directedtriagetoERC.In2seriesofpatientswithacutepancreatitisofsuspectedbiliaryetiology,allsubjectsunderwentsequen-tialEUSandERC(conductedbyseparate,blindedexam-iners).EUShadasensitivityof91%to97%andaccuracyof97%to98%forcholedocholithiasisdetection,similartoorbetterthantheperformanceofERCinthesestud-Inatrialthatrandomized140patientswithacutepancreatitisofsuspectedbiliaryetiologytoEUSversusERC,thebileductwassuccessfullyevaluatedmorefre-quentlywithEUS,andEUSwasassociatedwithatrendto-wardlessmorbidity.NopatientswithanegativebiliaryEUSÞndingexperiencedthedevelopmentofrecurrentsymptomsinmorethana2-yearmedianfollow-up,andEUSidentiÞedcholelithiasisin6of48patientsinitiallylabeledidiopathicafterunrevealingtransabdominalUSandERC.AMonteCarlodecisionanalysisrecentlycom-paredselectiveERC(forsevereABP,withsupportivecareformildABP)withtheEUS-ÞrstandMRC-Þrstapproaches.TheEUS-ÞrststrategywaspreferableforsevereABPinthisanalysis,withreducedcosts,fewerERCs,andfewercomplications.RECOMMENDATIONS1.Werecommendthattheinitialevaluationofsuspectedcholedocholithiasisshouldincludeserumliverbio-chemicaltestsandatransabdominalUSoftherightupperquadrant.444Thesetestsshouldbeusedtorisk-stratifypatientstoguidefurtherevaluationandmanagement.2.Werecommendthatpatientswithsymptomaticcholeli-thiasiswhoaresurgicalcandidatesandhavealowprobabilityofcholedocholithiasisproceedtocholecys-tectomywithoutadditionalbiliaryevaluation(Fig.13.Werecommendthatpatientswithanintermediateprobabilityofcholedocholithiasisundergofurthereval-uationwithpreoperativeEUSorMRCoranIOCFig.1Inthisgroupofpatients,wesuggestthatERCbedeferredunlessEUS,MRC,andIOCareunavailable,giventhelessfavorableriskproÞleof4.Werecommendthatpatientswithahighprobabilityofcholedocholithiasisundergoanevaluationofthebile Theroleofendoscopyintheevaluationofsuspectedcholedocholithiasis GASTROINTESTINALENDOSCOPYVolume71,No.1:2010www.giejournal.org ductwiththerapeuticcapability,generallypreoperativeERC(Fig.1Whenavailable,laparoscopicbileductexplorationcanserveasanalternativetoERC.5.WesuggestthatEUSorMRCbeconsideredinthediag-nosticevaluationofpostcholecystectomypatientssus-pectedofhavingcholedocholithiasiswheninitiallaboratoryandUSdataareabnormalyetnondiagnostic.6.WerecommendagainstearlyERCintheevaluationandmanagementofpatientswithmildABPintheabsenceofclearevidenceofaretainedstone.7.WerecommendearlyERCinpatientswithacutebiliarypancreatitisandconcomitantcholangitis,giventheobservedbeneÞtsinmorbidityandmortality.8.Wesuggestthatpatientswithacutebiliarypancreatitisandclinicalevidenceofbiliaryobstructionbeconsid-eredforearlyERC.WecannotrecommendfororagainstearlyERCinpatientswithpredictedse-vereacutebiliarypancreatitisintheabsenceofovertbiliaryobstructionorcholangitis,giventhelackofcon-sensusintheavailabledata.9.Aspatientswithacutebiliarypancreatitisareatleastatintermediateriskforcholedocholithiasis,wesuggestpre-operativeEUSorIOCbeconsideredforthesepatientswhencholangitisorbiliaryobstructionareAbbreviations:ABP,acutebiliarypancreatitis;CBD,commonbileduct;ERC,endoscopicretrogradecholangiography;IDUS,intraductalUS;IOC,intraoperativecholangiography;MRC,magneticresonancecholangiography.1.GuyattGH,OxmanAD,VistGE,etal;GRADEWorkingGroup.GRADE.anemergingconsensusonratingqualityofevidenceandstrengthofrecommendations.BMJ2008;336:924-6.2.EverhartJE,KhareM,HillM,etal.PrevalenceandethnicdifferencesingallbladderdiseaseintheUnitedStates.Gastroenterology1999;3.EverhartJE,RuhlCE.BurdenofdigestivediseasesintheUnitedStatesI:Overallanduppergastrointestinaldiseases.Gastroenterology2009;4.HunterJG.Laparoscopictranscysticbileductexploration.AmJSurg1992;163:53-6.5.RobinsonBL,DonohueJH,GunesS,etal.Selectiveoperativecholan-giography:appropriatemanagementforlaparoscopiccholecystec-tomy.ArchSurg1995;130:625-30.6.PetelinJB.Laparoscopiccommonbileductexploration.SurgEndosc2003;17:1705-15.7.O’NeillCJ,GilliesDM,GaniJS.Choledocholithiasis:overdiagnoseden-doscopicallyandundertreatedlaparoscopically.ANZJSurg2008;78:8.ChangL,LoSK,StabileBE,etal.Gallstonepancreatitis:aprospectivestudyontheincidenceofcholangitisandclinicalpredictorsofre-tainedcommonbileductstones.AmJGastroenterol1998;93:527-31.9.ChakA,HawesRH,CooperGS,etal.ProspectiveassessmentoftheutilityofEUSintheevaluationofgallstonepancreatitis.GastrointestEndosc1999;49:599-604.10.LiuCL,LoCM,ChanJKF,etal.DetectionofcholedocholithiasisbyEUSinacutepancreatitis:aprospectiveevaluationin100consecu-tivepatients.GastrointestEndosc2001;54:325-30.11.CohenME,SlezakL,WellsCK,etal.Predictionofbileductstonesandcomplicationsingallstonepancreatitisusingearlylaboratorytrends.AmJGastroenterol2001;96:3305-11.12.YangMH,ChenTH,WangSE,etal.Biochemicalpredictorsforabsenceofcommonbileductstonesinpatientsundergoinglaparo-scopiccholecystectomy.SurgEndosc2008;22:1620-4.13.BarkunAN,BarkunJS,FriedGM,etal.Usefulpredictorsofbileductstonesinpatientsundergoinglaparoscopiccholecystectomy.AnnSurg1994;220:32-9.14.OnkenJE,BrazerSR,EisenGM,etal.Predictingthepresenceofcholedocholithiasisinpatientswithsymptomaticcholelithiasis.AmJGastroenterol1996;91:762-7.15.PengWK,SheikhZ,Paterson-BrownS,etal.Roleofliverfunctiontestsinpredictingcommonbileductstonesinpatientswithacutecalculouscholecystitis.BrJSurg2005;92:1241-7.16.EinsteinDM,LapinSA,RallsPW,etal.Theinsensitivityofsonographyinthedetectionofcholedocholithiasis.AJRAmJRoentgenol1984;17.VallonAG,LeesWR,CottonPB.Grey-scaleultrasonographyinchole-staticjaundice.Gut1979;20:51-4.18.CronanJJ.USdiagnosisofcholedocholithiasis:areappraisal.Radiol-ogy1986;161:133-4.19.O’ConnorHJ,HamiltonI,EllisWR,etal.Ultrasounddetectionofchol-edocholithiasis:prospectivecomparisonwithERCPinthepostchole-cystectomypatient.GastrointestRadiol1986;11:161-4.20.LapisJL,OrlandoRC,MittelstaedtCA,etal.Ultrasonographyinthediagnosisofobstructivejaundice.AnnInternMed1978;89:61-3.21.BaronRL,StanleyRJ,LeeJKT,etal.Aprospectivecomparisonoftheevaluationofbiliaryobstructionusingcomputedtomographyandultrasonography.Radiology1982;145:91-8.22.MitchellSE,ClarkRA.Acomparisonofcomputedtomographyandsonographyincholedocholithiasis.AJRAmJRoentgenol1984;142:23.PedersenOM,NordgardK,KvinnslandS.Valueofsonographyinobstructivejaundice.Limitationsofbileductcaliberasanindexofobstruction.ScandJGastroenterol1987;22:975-81.24.ParulekarSG.Ultrasoundevaluationofbileductsize.Radiology1979;25.BrunetonJN,RouxP,FenartD,etal.Ultrasoundevaluationofcommonbileductsizeinnormaladultpatientsandfollowingcholecystectomy:areportof750cases.EurJRadiol1981;1:171-2.26.BacharGN,CohenM,BelenkyA,etal.Effectofagingontheadultextrahepaticbileduct:asonographicstudy.JUltrasoundMed2003;22:879-82.27.CostiR,SarliL,CarusoG,etal.Preoperativeultrasonographicassess-mentofthenumberandsizeofgallbladderstones:isitausefulpre-dictorofasymptomaticcholedochallithiasis.JUltrasoundMed2002;28.LiuTH,ConsortiET,KawashimaA,etal.Patientevaluationandmanagementwithselectiveuseofmagneticresonancecholangiog-raphyandendoscopicretrogradecholangiopancreatographybeforelaparoscopiccholecystectomy.AnnSurg2001;234:33-40.29.PratF,MeduriB,DucotB,etal.Predictionofcommonbileductstonesbynoninvasivetests.AnnSurg1999;229:362-8.30.BoseSM,MazumdarA,PrakashVS,etal.Evaluationofthepredictorsofcholedocholithiasis:comparativeanalysisofclinical,biochemical,radiological,radionuclear,andintraoperativeparameters.SurgToday2001;31:117-22.31.AbboudPAC,MaletPF,BerlinJA,etal.Predictorsofcommonbileductstonespriortocholecystectomy:ameta-analysis.GastrointestEndosc1996;44:450-9.32.TseF,BarkunJS,BarkunAN.Theelectiveevaluationofpatientswithsuspectedcholedocholithiasisundergoinglaparoscopiccholecystec-tomy.GastrointestEndosc2004;60:437-48. Theroleofendoscopyintheevaluationofsuspectedcholedocholithiasis www.giejournal.orgVolume71,No.1:2010GASTROINTESTINALENDOSCOPY 33.NassarwehNN,FlumDR.Roleofintraoperativecholangiographyinavoidingbileductinjury.JAmCollSurg2007:656-64.34.MetcalfeMS,OngT,BrueningMH,etal.Islaparoscopicintraoperativecholangiogramamatterofroutine?AmJSurg2004;187:475-81.35.ByrneMF,McLoughlinMT,MitchellRM,etal.Forpatientswithpre-dictedlowriskforcholedocholithiasisundergoinglaparoscopiccho-lecystectomy,selectiveintraoperativecholangiographyandpostoperativeendoscopicretrogradecholangiopancreatographyisaneffectivestrategytolimitunnecessaryprocedures.SurgEndosc2009;23:1933-7.36.NickkolghA,SoltaniyektaS,KalbasiH.Routineversusselectiveintra-operativecholangiographyduringlaparoscopiccholecystectomy:asurveyof2,130patientsundergoinglaparoscopiccholecystectomy.SurgEndosc2006;20:868-74.37.SahaiAV,MauldinPD,MarsiV,etal.Bileductstonesandlaparo-scopiccholecystectomy:adecisionanalysistoassesstherolesofintraoperativecholangiography,EUS,andERCP.GastrointestEndosc1999;49:334-43.38.UrbachDR,KhajancheeYS,JobeBA,etal.Cost-effectivemanage-mentofcommonbileductstones:adecisionanalysisoftheuseofendoscopicretrogradecholangiopancreatography(ERCP),intraoper-ativecholangiography,andlaparoscopicbileductexploration.SurgEndosc2001;15:4-13.39.FrossardJL,HadengueA,AmouyalG,etal.Choledocholithiasis:apro-spectivestudyofspontaneouscommonbileductstonemigration.GastrointestEndosc2000;51:175-9.40.OriaA,AlvarezJ,ChiapettaL,etal.Riskfactorsforacutepancreatitisinpatientswithmigratinggallstones.ArchSurg1989;124:1295-6.41.MartinDJ,VernonD,ToouliJ.Surgicalversusendoscopictreatmentofbileductstones.CochraneDatabaseSystRev2006;19:CD003327.42.CuschieriA,LezocheE,MorenoM,etal.E.A.E.S.multicenterprospec-tiverandomizedcontrolledtrialcomparingtwo-stageversussingle-stagemanagementofpatientswithgallstonediseaseandductalcal-culi.SurgEndosc1999;13:952-7.43.SgourakisG,KaraliotisK.Laparoscopiccommonbileductexplorationandcholecystectomyversusendoscopicstoneextractionandlaparo-scopiccholecystectomyforcholedocholithiasis:aprospectiveran-domizedstudy.MinervaChir2002;57:467-74.44.FanelliRD,GersinKS.Laparoscopicendobiliarystenting:asimplifiedapproachtothemanagementofoccultcommonbileductstones.JGastrointestSurg2001;5:74-80.45.MillerFH,HwangCM,GabrielH,etal.Contrast-enhancedhelicalCTofcholedocholithiasis.AJRAmJRoentgenol2003;181:125-30.46.SotoJA,AlvarezO,MuneraF,etal.Diagnosingbileductstones:comparisonofunenhancedhelicalCT,oral-contrastenhancedCTcholangiography,andMRcholangiography.AJRAmJRoentgenol2000;175:1127-34.47.NeitlichJD,TopazianM,SmithRC,etal.Detectionofcholedocholi-thiasis:comparisonofunenhancedhelicalCTandendoscopicretro-gradecholangiopancreatography.Radiology1997;203:753-7.48.TsengCW,ChenCC,ChenTS,etal.Cancomputedtomographywithcoronalreconstructionimprovethediagnosisofcholedocholithiasis?JGastroenterolHepatol2008;23:1586-9.49.AndersonSW,RhoE,SotoJA.Detectionofbiliaryductnarrowingandcholedocholithiasis:accuracyofportalvenousphasemultidetec-torCT.Radiology2008;247:418-27.50.RomagnuoloJ,BardouM,RahmeE,etal.Magneticresonancechol-angiopancreatography:ameta-analysisoftestperformanceinsus-pectedbiliarydisease.AnnInternMed2003;139:547-57.51.VermaD,KapadiaA,EisenGM,etal.EUSvsMRCPfordetectionofcholedocholithiasis.GastrointestEndosc2006;64:248-54.52.ZidiSH,PratF,LeGuenO,etal.Useofmagneticresonancecholan-giographyinthediagnosisofcholedocholithiasis:prospectivecomparisonwithareferenceimagingmethod.Gut1999;44:118-22.53.SugiyamaM,AtomiY,HachiyaJ.Magneticresonancecholangiogra-phyusinghalf-Fourieracquisitionfordiagnosingcholedocholithiasis.AmJGastroenterol1998;93:1886-90.54.BoraschiP,NeriE,BracciniG,etal.Choledocholithiasis:diagnosticac-curacyofMRcholangiopancreatography3yearexperience.MRI1999;17:1245-53.55.PolkowskiM,PaluckiJ,RegulaJ,etal.Helicalcomputedtomographiccholangiographyversusendosonographyforsuspectedbileductstones:aprospectiveblindedstudyinnon-jaundicedpatients.Gut1999;45:744-9.56.CabadaGiadisT,SarriaOctaviodeToledoL,Martinez-BerganzaAsen-sioMT,etal.HelicalCTcholangiographyintheevaluationofthebiliarytract:applicationtothediagnosisofcholedocholithiasis.Ab-domImaging2002;27:61-70.57.MachiJ,TateishiT,OishiAJ,etal.Laparoscopicultrasonographyver-susoperativecholangiographyduringlaparoscopiccholecystec-tomy:reviewoftheliteratureandacomparisonwithopenintraoperativeultrasonography.JAmCollSurg1999;188:361-7.58.KohutM,Nowakowska-DulawaE,MarekT,etal.Accuracyoflinearultrasonographyintheevaluationofpatientswithsuspectedcommonbileductstones.Endoscopy2002;34:299-303.59.LachterJ,RubinA,ShillerM,etal.LinearEUSforbileductstones.GastrointestEndosc2000;51:51-4.60.TseF,LiuL,BarkunAN,etal.EUS:ameta-analysisoftestperfor-manceinsuspectedcholedocholithiasis.GastrointestEndosc2008;67:235-44.61.GarrowD,MillerS,SinhaD,etal.Endoscopicultrasound:ameta-analysisoftestperformanceinsuspectedbiliaryobstruction.ClinGastroenterolHepatol2007;5:616-23.62.KondoS,IsayamaH,AkahaneM,etal.Detectionofcommonbileductstones:comparisonbetweenendoscopicultrasonography,magneticresonancecholangiography,andhelical-computed-tomo-graphiccholangiography.EurJRadiol2005;54:271-5.63.AubeC,DelormeB,YzetT,etal.MRcholangiopancreatographyversusendoscopicsonographyinsuspectedcommonbileductlithi-asis:aprospective,comparativestudy.AJRAmJRoentgenol2005;184:55-62.64.SugiyamaM,AtomiY.Endoscopicultrasonographyfordiagnosingcholedocholithiasis:aprospectivecomparativestudywithultraso-nographyandcomputedtomography.GastrointestEndosc1997;65.BournetB,MigueresI,DelacroixM,etal.Earlymorbidityofendo-scopicultrasound:13years’experienceatareferralcenter.Endos-copy2006;38:349-54.66.MortensenMB,FristrupC,HolmFS,etal.Prospectiveevaluationofpatienttolerability,satisfactionwithpatientinformation,andcompli-cationsinendoscopicultrasonography.Endoscopy2005;37:146-53.67.RoschT,DittlerHJ,FockensP,etal.Majorcomplicationsofendo-ography:resultsofasurveyof42,105cases[abstract].GastrointestEndosc1993;39:341.68.PratF,AmouyalG,AmouyalP,etal.Prospectivecontrolledstudyofendoscopicultrasonographyandendoscopicretrogradecholangiog-raphyinpatientswithsuspectedcommonbileductlithiasis.Lancet1996;347:75-9.69.TsengLJ,JaoYT,MoLR,etal.Over-the-wireUScatheterprobeasanadjuncttoERCPinthedetectionofcholedocholithiasis.GastrointestEndosc2001;54:720-3.70.FreemanML,NelsonDB,ShermanS,etal.Complicationsofendo-scopicbiliarysphincterotomy.NEnglJMed1996;335:909-18.71.LoperfidoS,AngeliniG,BenedettiG,etal.MajorearlycomplicationsfromdiagnosticandtherapeuticERCP:aprospectivemulticenterstudy.GastrointestEndosc1998;48:1-10.72.FreemanML,DiSarioJA,NelsonDB,etal.Riskfactorsforpost-ERCPpancreatitis:aprospective,multicenterstudy.GastrointestEndosc2001;54:425-34.73.MasciE,TotiG,MarianiA,etal.Complicationsofdiagnosticandther-apeuticERCP:aprospective,multicenterstudy.AmJGastroenterol2001;96:417-23.74.ChristensenM,MatzenP,SchulzeS,etal.ComplicationsofERCP:aprospectivestudy.GastrointestEndosc2004;60:721-31. Theroleofendoscopyintheevaluationofsuspectedcholedocholithiasis GASTROINTESTINALENDOSCOPYVolume71,No.1:2010www.giejournal.org 75.WilliamsEJ,TaylorS,FaircloughP,etal.RiskfactorsforcomplicationfollowingERCP:resultsofalarge-scale,prospectivemulti-centerstudy.Endoscopy2007;39:793-801.76.CottonPB,GarrowDA,GallagherJ,etal.Riskfactorsforcomplica-tionsafterERCP:amultivariateanalysisof11,497proceduresover12years.GastrointestEndosc2009[Epubaheadofprint].77.DasA,IsenbergG,WongRCK,etal.Wire-guidedintraductalUS:anadjuncttoERCPinthemanagementofbileductstones.GastrointestEndosc2001;54:31-6.78.ChenYK,PleskowDK.SpyGlasssingleoperatorperoralcholangio-pancreatoscopysystemforthediagnosisandtherapyofbileductdisorders:aclinicalfeasibilitystudy.GastrointestEndosc2007;65:79.WeickertU,JakobsR,HahneM,etal.Cholangioscopyaftersuccessfultreatmentofcomplicatedcholedocholithiasis:isstonefreereallystonefree?[inGerman].DtschMedWochenschr2003;128:481-4.80.LarghiA,WaxmanI.Endoscopicdirectcholangioscopybyusinganultra-slimupperendoscope:afeasibilitystudy.GastrointestEndosc2006;63:853-7.81.LeeYT,ChanFKL,LeungWK,etal.ComparisonofEUSandERCPintheinvestigationwithsuspectedbiliaryobstructioncausedbychol-edocholithiasis:arandomizedstudy.GastrointestEndosc2008;67:82.PolkowskiM,RegulaJ,TilszerA,etal.Endoscopicultrasoundversusendoscopicretrogradecholangiographyforpatientswithintermedi-ateprobabilityofbileductstones:arandomizedtrialcomparingtwomanagementstrategies.Endoscopy2007;39:296-303.83.LiuCL,FanST,LoCM,etal.Comparisonofearlyendoscopicultraso-nographyandendoscopicretrogradecholangiopancreatographyinthemanagementofacutebiliarypancreatitis:aprospectiverandom-izedstudy.ClinGastroenterolHepatol2005;3:1238-44.84.KarakanT,CindorukM,AlagozluH,etal.EUSversusendoscopicret-rogradecholangiographyforpatientswithintermediateprobabilityofbileductstones:aprospectiverandomizedtrial.GastrointestEn-dosc2009;69:244-52.85.BuscariniE,TansiniP,VallisaD,etal.EUSforsuspectedcholedocho-lithiasis:dobenefitsoutweighcosts?aprospectivecontrolledstudy.GastrointestEndosc2003;57:510-8.86.NiderauC,MullerJ,SonenbergA,etal.Extrahepaticbileductsinhealthsubjects,inpatientswithcholelithiasis,andinpostcholecys-tectomypatients:aprospectiveultrasonicstudy.JClinUltrasound1983;11:23-7.87.ChawlaS,TrickWE,GilkeyS,etal.Doescholecystectomystatusinflu-encethecommonbileductdiameter?Amatched-pairanalysis.DigDisSci2009[Epubaheadofprint].88.FirooziB,ChoungR,DiehlDL.Bileductdilationwithchronicmeth-adoneuseinasymptomaticpatients:ERCPfindingsin6patients.GastrointestEndosc2003;58:127-30.89.SharmaSS.SphincterofOddidysfunctioninpatientsaddictedtoopium:anunrecognizedentity.GastrointestEndosc2002;55:90.TerhaarOA,AbbasS,ThorntonFJ,etal.Imagingpatientswith‘‘post-cholecystectomysyndrome’’:analgorithmicapproach.ClinRadiol2005;60:78-84.91.CantoMI,ChakA,StellatoT,etal.Endoscopicultrasonographyversuscholangiographyforthediagnosisofcholedocholithiasis.GastrointestEndosc1998;47:439-48.92.CorfieldAP,CooperMJ,WilliamsonRCN.Acutepancreatitis:alethaldiseaseofincreasingincidence.Gut1985;26:724-9.93.WilsonC,ImrieCW,CarterDC.Fatalacutepancreatitis.Gut1988;29:94.AcostaJM,RubioGalliOM,RossiR,etal.Effectofdurationofampul-larygallstoneobstructiononseverityoflesionsofacutepancreatitis.JAmCollSurg1997;184:499-505.95.NeoptolemosJP,Carr-LockeDL,LondonNJ,etal.Controlledtrialofurgentendoscopicretrogradecholangiopancreatographyandendoscopicsphincterotomyversusconservativetreatmentforacutepancreatitisduetogallstones.Lancet1988;2:979-83.96.FanST,LaiECS,MokFPT,etal.Earlytreatmentofacutebiliarypancreatitisbyendoscopicpapillotomy.NEnglJMed1993;328:97.NowakA,Nowakowska–DulawaE,MarekT,etal.Finalresultsoftheprospective,randomized,controlledstudyonendoscopicsphincter-otomyversusconventionalmanagementinacutebiliarypancreatitis[abstract].Gastroenterology1995;108(Suppl):A380.98.RansonJH,RifkindKM,RosesDF,etal.Prognosticsignsandtheroleofoperativemanagementinacutepancreatitis.SurgGynecolObstet99.BlameySL,ImrieCW,O’NeillJ,etal.Prognosticfactorsinacutepan-creatitis.Gut1984;25:1340-6.100.FolschUR,NitscheR,LudtkeR,etal.EarlyERCPandpapillotomycomparedwithconservativetreatmentforacutebiliarypancreatitis;theGermanStudyGrouponacutebiliarypancreatitis.NEnglJMed1997;336:237-42.101.PetrovMS,vanSantvoortHC,BesselinkMG,etal.Earlyendoscopicretrogradecholangiopancreatographyversusconservativemanage-mentinacutebiliarypancreatitiswithoutcholangitis:ameta-analysisofrandomizedtrials.AnnSurg2008;247:250-7.102.AcostaJM,KatkhoudaN,DebianKA,etal.Earlyductaldecompres-sionversusconservativemanagementforgallstonepancreatitiswithampullaryobstruction:aprospectiverandomizedclinicaltrial.AnnSurg2006;243:33-40.103.OriaA,CimminoD,OcampoC,etal.Earlyendoscopicinterventionversusearlyconservativemanagementinpatientswithacutegall-stonepancreatitisandbiliopancreaticobstruction:arandomizedclinicaltrial.AnnSurg2007;245:10-7.104.SugiyamaM,AtomiY.Acutebiliarypancreatitis:therolesofendo-scopicultrasonographyandendoscopicretrogradecholangiopan-creatography.Surgery1998;124:14-21.105.PratF,EderyJ,MeduriB,etal.EarlyEUSofthebileductbeforeendoscopicsphincterotomyforacutebiliarypancreatitis.Gastroint-estEndosc2001;54:724-9.106.RomagnuoloJ,CurrieG.CalgaryAdvancedTherapeuticEndoscopyCenter(ATEC)studygroup.Noninvasivevs.selectiveinvasivebiliaryimagingforacutebiliarypancreatitis:aneconomicevaluationbyusingdecisiontreeanalysis.GastrointestEndosc2005;61:86-97.Preparedby:ASGESTANDARDSOFPRACTICECOMMITTEEJohnT.MapleTamirBen-MenachemMichelleA.AndersonVasundharaAppalaneniSubhasBanerjeeBrooksD.CashLaurelFisherM.EdwynHarrisonRobertD.FanelliNorioFukamiStevenO.IkenberryRajeevJainKhalidKhanMaryLeeKrinskyLauraStrohmeyerJasonA.Dominitz(Chair)ThisdocumentisaproductoftheStandardsofPracticeCommittee.ThisdocumentwasreviewedandapprovedbytheGoverningBoardoftheAmericanSocietyforGastrointestinalEndoscopy.ThisdocumentwasendorsedbytheSocietyofAmericanGastrointestinalandEndoscopicSurgeons(SAGES)GuidelinesCommitteeandbytheSAGESBoardofGovernors. Theroleofendoscopyintheevaluationofsuspectedcholedocholithiasis www.giejournal.orgVolume71,No.1:2010GASTROINTESTINALENDOSCOPY