Introduction

Common bile duct (CBD) dilation can be associated with a wide range of underlying conditions, from benign to significant pathology, including malignancy¹. A recently proposed score by Raza et al. aims to predict the likelihood of significant findings on endoscopic ultrasound (EUS) in patients with incidental CBD dilation², potentially optimizing its use. This study aims to validate this score in a cohort of patients who previously underwent EUS for incidental CBD dilation.

Aims & Methods

Patients with incidental CBD dilation (≥6mm or ≥8mm post-cholecystectomy) who underwent EUS and met the inclusion criteria were retrospectively analyzed. Patient demographics, clinical, laboratory and imaging data were collected to calculate the score: age ≥70 years (1 point), acute non-billiary type abdominal pain (2 points), previous endoscopic retrograde cholangiopancreatography (2 points), CBD diameter ≥15mm or ≥17mm if prior cholecystectomy (2 points). EUS findings were reviewed to identify outcomes.

Results

Sixty-five patients met the inclusion criteria for analysis, 39 females (60%) and 26 males (40%), mean age of 71.5 ± 8.5 years. Overall yield of EUS for significant findings was 21.5%, including 8 patients with choledocolithiasis (12.3%), 4 patients with ampullary adenoma (6.2%), 1 patient with a biliary mass (1.5%) and 1 patient with a pancreatic mass (1.5%). Among the cohort, 23 patients (35.4%) had a score of 0 and none had a significant finding. Thus, a score ≥1 had a sensitivity of 100% and specificity of 45.1%, reliably excluding significant findings. A score ≥3 had a sensitivity of 71.4% and a specificity of 94.1% for identifying meaningful pathology, enabling the identification of high-risk patients with greater precision.

Conclusion

The predictive score effectively stratifies patients with incidental CBD dilation, potentially reducing unnecessary EUS in low-risk individuals while prioritizing high-risk cases. This model enhances resource utilization and targeted care. Further research in larger cohorts may confirm its generalizability.

References

1. Kelly NM, Tharian B, Tham TCK. Natural history of unexplained biliary dilation. Gut 2011;60(Suppl 1):A32-42.
2. Raza, Z., Altayar, O., Mahmoud, T., Abusaleh, R., Ghazi, R., Early, D., Kushnir, V. M., Lang, G., Sloan, I., Hollander, T., Rajan, E., Storm, A. C., Abu Dayyeh, B. K., Chandrasekhara, V., & Das, K. K. (2024). Clinical predictors of significant findings on EUS for the evaluation of incidental common bile duct dilation.Gastrointestinal Endoscopy,100(4), 670–678.e1. https://doi.org/10.1016/j.gie.2024.04.2902

Introduction

Acute biliary pancreatitis (ABP) has been shown to be associated with increasing incidence and health-care costs, and possibly higher mortality than other etiologies. Despite the existence of various scoring systems, early and accurate risk stratification remains difficult. Due to heterogeneity of populations, focusing on one etiology might reveal important insights concerning predictors of outcome.

Aims & Methods

We conducted a retrospective, multicenter cohort study including all patients admitted with ABP between 2018 and 2021 at two hospitals. Epidemiological, clinical, and outcome data were analyzed. The main clinical outcome of interest was a hierarchical composite endpoint of five mutually exclusive clinical states: (i) death (90-day all-cause mortality), (ii) severe AP and/or admission to the intensive care unit (ICU), (iii) endoscopic, interventional radiological, or surgical interventions, (iv) moderately-severe AP, (v) mild AP. Univariable logistic regression identified parameters associated with worse outcomes, which were then tested in multivariable models. Emphasis was placed on early availability and clinical practicality of predictors. We aimed to stratify patients into outcome trajectories reflecting both health impact and healthcare resource utilization.

Results

Out of 569 total acute pancreatitis cases, 217 (38.1%) patients had ABP (mean age 65.9 ±17.4 years; median length of stay (LOS) 7 days, IQR 4;11) Mild, moderately-severe, and severe disease occurred in 62.2%, 30.0%, and 7.8% of patients. All-cause 90-day mortality was 2.3%. Several parameters were significantly (p<0.05) associated with worse outcomes, including BISAP and the Charlson comorbidity index (CCI) (p<0.001). Individually, BISAP and CCI classified patients reasonably, however, wide prognostic uncertainty persisted. When combining BISAP and CCI (BISAP-C), 5 discrete risk groups were identified, ranging from low (group 1, BISAP 0-2 & CCI 0-2) to very-high risk (group 5, BISAP 3-5 & CCI ≥6) (see Table 1). The prevalence of severe outcomes (i–iii) increased across these strata: 2.4% (Group 1), 9.5% (Group 2), 27.3% (Group 3), 60% (Group 4), and 62.5% (Group 5), with LOS also significantly longer in higher-risk groups (p<0.001). Mortality was 50% in group 5, while, importantly, 97.6% of patients in group 1 experienced mild-to-moderate AP without ICU admission, persistent organ dysfunction, surgical or endoscopic interventions, and no fatality, supporting potential early discharge. This also occurred in 90.5% of group 2. Notably, Groups 1 and 2 together comprised nearly 80% of the cohort.

Conclusion

Comorbidity seems to play a major role concerning worse outcomes in ABP. The combination of CCI and BISAP (BISAP-C), both comprised of early-on and easily available parameters, offers improved early prognostic discrimination and may provide tailored, individualized management and healthcare resource utilization.