Evaluation of ASGE Criteria for Prediction of Choledocholithiasis: Can Early Endoscopic Ultrasound Utilization Make the Prediction More Accurate?

Background: ASGE predictive model for the detection of choledocholithiasis is a reasonable approach for the management of patients with cholelithiasis. Surgeons do not pursue cholecystectomy without evaluation of the biliary system when laboratory tests and diagnostic imaging evidence show biliary duct involvement. Literature revisions reveal that the prediction of choledocholithiasis based on ASGE criteria suffers from poor accuracy which results in unnecessary ERCPs. We decided to estimate the sensitivity and specificity of the ASGE predictive model for the detection of choledocholithiasis with the hope that early EUS would obviate the need for unnecessary ERCPs among highly probable patients for choledocholithiasis based on ASGE criteria.    Methods: This is a prospective intervention and control study on the accuracy of ASGE criteria for the prediction of choledocholithiasis. To evaluate the sensitivity and specificity of ASGE criteria, patients were followed in two groups of controls who were treated based on ASGE guidelines and cases who underwent primary EUS. The clinical relevance of the ASGE criteria was estimated by sensitivity and specificity using SPSS Statistics 28 software. Then, absolute risk reduction utilizing primary EUS was also calculated.    Results: The sensitivity and specificity of the ASGE predictive guideline for choledocholithiasis were estimated to be 62.31% and 51.85%, respectively. Evaluation of the ASGE guideline also revealed that patients in the intermediate probability group who finally required ERCP based on EUS results (false-negatives) were estimated to be 49.1% and patients who were predicted to require ERCP but finally did not need ERCP (false positives) were estimated to be 37.68%. The comparison of the two groups revealed the need for ERCP in about 55.56% of the primary EUS group and 77.42% in the ASGE group. Utilization of primary EUS reduced the need for ERCP by an absolute risk reduction of 0.299. (Primary Endpoint)    Conclusion: ASGE guideline is associated with the overestimation of ERCP in cholelithiasis. The usage of primary EUS will reduce the need for ERCP.