Choledocholithiasis: ASGE releases guideline for endoscopy use

  • Buxbaum JL & al.
  • Gastrointest Endosc
  • 09/04/2019

  • Jenny Blair, MD
  • Clinical Essentials
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  • For patients with bile duct stones, patient selection is important to minimize endoscopic treatment complications.
  • Save biliary endoscopy for those with the highest likelihood of ductal stones.

Why this matters

  • In up to 15% of endoscopic retrograde cholangiopancreatography (ERCP)-guided bile duct stone treatments, major adverse events occur.


  • American Society for Gastrointestinal Endoscopy (ASGE) Standard of Practice Guideline.

Key recommendations

  • With intermediate choledocholithiasis risk, diagnose using endoscopic ultrasound (EUS) or magnetic resonance cholangiopancreatography (MRCP; conditional recommendation; low-quality evidence [LQE]).
  • For gallstone pancreatitis without cholangitis or biliary obstruction/choledocholithiasis, avoid urgent ERCP (strong recommendation, LQE).
  • For large bile duct stones, use endoscopic sphincterotomy plus large balloon dilation, not endoscopic sphincterotomy alone (conditional recommendation, moderate-quality evidence).
  • For large/difficult choledocholithiasis, use intraductal therapy or conventional therapy with papillary dilation (conditional recommendation, very LQE).
  • For difficult choledocholithiasis, stents may help but require eventual exchange or removal.
  • For mild gallstone pancreatitis, perform cholecystectomy during same admission.
  • High-risk criteria prompting ERCP:
    • Common bile duct (CBD) stone on ultrasound or cross-sectional imaging.
    • Total bilirubin >4 mg/dL, dilated CBD.
    • Ascending cholangitis.
  • For cholecystectomy in patients with high choledocholithiasis risk or positive intraoperative cholangiography, perform pre- or postoperative ERCP or laparoscopic treatment. 
  • For Mirizzi syndrome, resect gallbladder; peroral cholangioscopic therapy could replace surgery.
  • Hepatolithiasis requires multidisciplinary approach.