Diagnostic Imaging Pathways - Laparoscopic Cholecystectomy
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This pathway provides guidance on preoperative imaging of adult patients prior to laproscopic cholecystectomy.
Date reviewed: January 2012
Date of next review: 2017/2018
Published: January 2012
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The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
 | None | 0 |
 | Minimal | < 1 millisieverts |
 | Low | 1-5 mSv |
 | Medium | 5-10 mSv |
 | High | >10 mSv |
Images
Image GalleryNote: These images open in a new page | ||
|---|---|---|
| 1 |  |
Cholelithiasis Image 1 (Ultrasound): Calculi in the gallbladder (green crosses). |
| 2 |  |
Choledocholithiasis Image 2 (CT Cholangiogram): Three small filling defects (arrow) are seen within the common bile duct representing intraductal calculi. |
| 3 |  |
Choledocholithiasis Image 3 (ERCP): Gallstone present in the dilated common bile duct. |
| 4 |  |
Choledocholithiasis Image 4 (MRCP): Gallstone present in the dilated common bile duct (arrow). |
| 5 |  |
Acute cholecystitis
Image 5: Cholecystectomy showing acute cholecystitis with gallbladder wall oedema, vascular congestion and purulent exudate (blue arrow) caused by a massive cholesterol stone. |
| 6 |  |
Acute Cholecystitis
Image 6 (H&E, x2.5): Histological section of severe acute cholecystitis showing extensive ulceration of the mucosa, haemorrhage, oedema and a dense transmural infiltrate of neutrophils and mononuclear inflammatory cells. |
Teaching Points
Teaching Points
- The aim of investigation is to identify and treat patients with common bile duct (CBD) stones prior to surgery
- Low probability of a stone - normal liver function tests (LFTs), normal CBD on ultrasound, previously abnormal LFTs or past history of pancreatitis
- High probability of a stone - cholestatic jaundice, abnormal LFTs, abnormal CBD on trans-abdominal ultrasound or current episode of pancreatitis
- If surgical expertise in laparoscopic cholecystectomy, intra-operative cholangiogram and laparoscopic stone removal is available proceed directly to this option
- Non-invasive methods of evaluation include CT cholangiography, MR cholangiopancreatographyy and endoscopic US (EUS)
- Endoscopic retrograde cholangiopancreatography (ERCP) enables retrieval of CBD stones prior to surgery
ct
Computed Tomography (CT) Cholangiogram
- >90% sensitivity and specificity for detection of bile duct stones 25,26,27
- Alternative for detection of CBD stones in intermediate risk group, if MRCP or EUS unavailable 25,26,27
- Used by some surgeons, to evaluate aberrant bile ducts before laparoscopic cholecystectomy 28
- Disadvantages
- Unsuccessful if bilirubin levels are more than twice the upper limit of normal
- Potential risk of contrast toxicity
- Radiation exposure
- Does not offer therapeutic opportunity
ercp
Endoscopic Retrograde Cholangiopancreatography (ERCP)
- Routine use of ERCP to detect common bile duct stones before laparoscopic cholecystectomy is not indicated in low risk groups 3,9,11
- ERCP is indicated before laparoscopic cholecystectomy in patients in whom there is high clinical suspicion of choledocholithiasis, based on clinical, biochemical and ultrasonographic criteria 3,10,11,12,13
- Highly accurate in diagnosis and treatment of common bile duct stones (96% success rate for endoscopic sphincterotomy) 3,10,11,12,14
- Limitations - up to 5% complication rate (e.g. pancreatitis), ~0.5-1% mortality rate and ~8% cannulation failure rate 11,12,13,15
eus
Endoscopic Ultrasound (EUS)
- Highly accurate (>95%) for the detection of choledocholithiasis (comparable to ERCP but superior to CT and US) 3,4,6,7,18,19,20,21,32
- No significant difference in diagnostic accuracy compared to MRCP. 32 Consider patient suitability, availability and local expertise in selecting appropriate modality 33
- Comparable sensitivity to that of ERCP for detection of choledocholithiasis 18,19
- Can be used to detect common bile duct stones in intermediate risk group who are good surgical candidates 3,18,22
- Not suitable in 19
- Severe acute biliary pancreatitis or cholangitis, since it may delay endoscopic treatment
- In elderly and high-risk surgical patients because in this population the treatment of choice is endoscopic sphincterotomy if CBD stones are detected
- Limitations
- Limited availability
- Invasive
- Technically impossible in cases of previous gastric surgery
- Difficult to interpret following sphincterotomy or previous biliary stenting procedures due to presence of air in the biliary tract
- Does not offer therapeutic opportunity
high
High Risk Features
- Patients with the following clinical, biochemical, or sonographic features are considered at high risk of having a CBD stone
- Cholestatic jaundice
- Abnormal liver function tests
- Abnormal CBD on US (i.e. dilated ducts, CBD stones)
- Current episode of pancreatitis
low
Low Risk Features
- Patients with the following clinical, biochemical, or sonographic features are considered at low risk of having a CBD stone
- Normal liver function tests
- Normal CBD on ultrasound
- Previously abnormal LFTs and past history of pancreatitis remains low risk
mrcp
Magnetic Resonance Cholangiopancreatography (MRCP)
- Sensitivity of over 84% and specificity of over 90% for the diagnosis of CBD stones, with most false negative results being for stones less than 5mm in diameter 21,23,24,25,31,32
- A meta-analysis of 7 studies showed no statistically significant difference in diagnostic accuracy between MRCP and EUS for the detection of CBD stones. 32 Consider patient suitability, availability and local expertise in selecting appropriate modality 33
- Advantages
- Non-invasive
- No ionising radiation
- Allows diagnosis and treatment planning without invasive cholangiography
- Limitations
- Does not offer therapeutic opportunity
- Expensive and limited availability
- Less sensitive for stones smaller than 5mm in diameter 31
us
Ultrasound
- Has a sensitivity of 36-75% and specificity of 83-97% for the diagnosis of CBD stones 5,8,16,17,29,30
- Limitations 8
- False negative results due to inability to see the extra-hepatic biliary tree (often because of interposed bowel gas) and absence of biliary dilation in the presence of obstruction
- Advantages
- Non-invasive and readily available
- No ionising radiation
References
References
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Abboud PAC, Malet PF, Berlin JA, et al. Predictors of common bile duct stone prior to cholecystectomy: a meta-analysis. Gastrointest Endosc. 1996;44:450-9. (Level II evidence). View the reference
- Kama NA, Atli M, Doganay M, et al. Practical recommendations for the prediction and management of common bile duct stones in patients with gallstones. Surg Endosc. 2001;15:942-5. (Level II evidence). View the reference
- Berdah SV, Orsoni P, Bege T, et al. Follow-up of selective endoscopic ultrasonography and/or endoscopic retrograde cholangiography prior to laparoscopic cholecystectomy: a prospective study of 300 patients. Endoscopy. 2001;33:216-20. (Level II evidence). View the reference
- Canto MI, Chak A, Stellato T, et al. Endoscopic ultrsonography versus cholangiography for the diagnosis of choledocholithiasis. Gastrointest Endosc. 1998;47:439-48. (Level II/III evidence)
- Stott MA, Farrands PA, Guyer PB, et al. Ultrasound of the common bile duct in patients undergoing cholecystectomy. J Clin Ultrasound. 1991:19:73-6. (Level II/III evidence)
- Sugiyama M, Atomi Y. Endoscopic Ultrasonography for diagnosing choledocholithiasis: a prospective comparative study with ultrasonography and computed tomography. Gastrintest Endosc. 1997;45:143-6. (Level II evidence). View the reference
- Amouyal P, Amouyal G, Levy P, et al. Diagnosis of choledocholithiasis by endoscopic ultrasonography. Gastroenterology. 1994;106:1062-7. (Level II/III evidence)
- Dong B, Chen M. Improved sonographic visualisation of choledocholithiasis. J Clin Ultrasound. 1987;15:185-90. (Level II/III evidence)
- Urbach DR, Khajanchee YS, Jobe BA, et al. Cost-effective management of common bile duct stones: a decision analysis of the use of endoscopic retrograde cholangiopancreatography (ERCP), intraoperative cholangiography, and laparoscopic bile duct exploration. Surg Endosc. 2001;15:4-13. (Level III evidence)
- Cuschieri A, Lezoche E, Morino M, et al. E.A.E.S multicenter prospective randomized trial comparing two-stage vs single-stage management of patients with gallstone disease and ductal calculi. Surg Endosc. 1999;13:952-7. (Level II evidence). View the reference
- Neuhaus H, Feussner H, Ungeheuer A, et al. Prospective evaluation of the use of endoscopic retrograde cholangiography prior to laparoscopic cholecystectomy. Endoscopy. 1992;24:745-9. (Level II/III evidence)
- Rieger R, Wayand W. Yield of prospective, noninvasive evaluation of the common bile duct combined with selective ERCP/sphincterotomy in 1390 consecutive laparoscopic cholecystectomy patients. Gastrointest Endosc. 1995;42:6-12. (Level II/III evidence)
- Rijna H, Borgstein PJ, Meuwissen SGM, et al. Selective preoperative endoscopic retrograde cholangiopancreatography in laparoscopic biliary surgery. Br J Surg. 1995;82:1130-3. (Level II/III evidence)
- Bergamaschi R, tuech JJ, Braconier L, et al. Selective endoscopic retrograde cholangiography prior to laparoscopic cholecystectomy for gallstones. Am J Surg. 1999;178:46-9. (Level II evidence). View the reference
- Freeman ML, Nelson DB, Sherman S, et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med. 1996;335:909-18. (Level II evidence). View the reference
- Khandelwal N, Suri S, Malik M, et al. Ultrasound in choledocholithiasis. J Indian Med Assoc. 1991;89:95-7. (Level III evidence)
- Thornton JR, Lobo AJ, Lintott DJ, Axon AT. Value of ultrasound and liver function tests in determining the need for endoscopic retrograde cholangiopancreatography in unexplained abdominal pain. Gut. 1992;33:1559-61. (Level III evidence)
- Palazzo L, Girollet PP, Salmeron M, et al. Value of endoscopic ultrasonography in the diagnosis of common bile duct stones: comparison with surgical exploration and ERCP. Gastrointest Endosc. 1995;42:225-31. (Level II/III evidence)
- Prat F, Amouyal G, Amouyal P, et al. Prospective controlled study of endoscopic ultrasonography and endoscopic retrograde cholangiography in patients with suspected common bile duct lithiasis. Lancet. 1996;347:75-9. (Level II/III evidence)
- Aubertin JM, Levoir D, Bouillot JL, et al. Endoscopic ultrasonography immediately prior to laparoscopic cholecystectomy: a prospective evaluation. Endoscopy. 1996;28:667-73. ( Level II/III evidence)
- De Ledinghen V, Lecesne R, Raymond JM, et al. Diagnosis of choledocholithiasis: EUS or magnetic resonance cholangiography? A prospective controlled study. Gastrointest Endosc. 1999;49:26-31. (Level III evidence)
- Sahai AV, Mauldin PD, Marsi V, Hawes RH, et al. Bile duct stones and laparoscopic cholecystectomy: a decision analysis to assess the roles of intraoperative cholangiography, EUS, and ERCP. Gastrointest Endosc. 1999;49:334-43. (Level II/III evidence)
- Demartines N, Eisner L, Schnabel K, et al. Evaluation of magnetic resonance cholangiography in the management of bile duct stones. Arch Surg. 2000;135:148-52. (Level II/III evidence)
- Dwerryhouse SJ, Brown E, Vipond MN, et al. Prospective evaluation of magnetic resonance cholangiography to detect common bile duct stones before laparoscopic cholecystectomy. Br J Surg. 1998;85:1364-6. (Level II/III evidence)
- Soto JA, Alvarez O, Munera F, et al. Diagnosing bile duct stones: comparison of unenhanced helical CT, oral contrast enhanced CT cholangiography, and MR cholangiography. AJR Am J Roentgenol. 2000;175:1127-34. (Level III evidence)
- Polkowski M, Palucki J, Regula J, et al. Helical computed tomographic cholangiography versus endosonography for suspected bile duct stones: a prospective blinded study in non-jaundiced patients. Gut. 1999;45:744-9. (Level II/III evidence)
- Van Beers BE, Lacrosse M, Trigaux JP, et al. Noninvasive imaging of the biliary tree before or after laparoscopic cholesystectomy: use of three-dimensional spiral CT cholangiography. AJR Am J Roentgenol. 1994;162:1331-5. (Level III evidence)
- Hirao K, Miyazaki A, Fujimoto T, et al. Evaluation of aberrant bile ducts before laparoscopic cholecystectomy: helical CT cholangiography versus MR cholangiography. AJR Am J Roentgenol. 2000;175:713-20. (Level III evidence)
- O'Connor HJ, Hamilton I, Ellis WR, et al. Ultrasound detection of choledocholithiasis: prospective comparison with ERCP in the post cholecystectomy patient. Gastrointest Radiol. 1986;11:161-4. (Level II evidence). View the reference
- Cronan JJ. US diagnosis of choledocholithiasis: a reappraisal. Radiology. 1986;161:133-4. (Level III evidence)
- Griffin N, Wastle ML, Dunn WK, Ryder SD, Beckingham IJ. Magnetic resonance cholangiopancreatography versus endoscopic retrograde cholangiopancreatography in the diagnosis of choledocholithiasis. Eur J Gastroenterol Hepatol. 2003;15:809-13 (Level II evidence). View the reference
- Ledro-Cano D. Suspected choledocholithiasis: endoscopic ultrasound or magnetic resonance cholangio-pancreatography? A systematic review. Eur J Gastroenterol Hepatol. 2007;19(11);1007-11. (Level I/II evidence)
- Williams EJ, Green J, Beckingham I, Parks R, Martin D, Lombard M. Guidelines on the management of common bile duct stones (CBDS). Gut. 2008;57(7);1004-21. (Guidelines)
Further Reading
- Shah SK, Mutignani, Costamagna G, et al. Therapeutic biliary endoscopy. Endoscopy. 2002;34(1):43-53. (Review article)
- Palazzo L. Which test for common bile duct stones? Endoscopic and intraductal ultrasonography. Endoscopy. 1997;29:655-65. (Review article)
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