Investigation of cholesterol gallstone disease.

摘要

Piero Portincasa and colleagues' Seminar (July 15, p 230)1 was a helpful summary of the pathophysiology of cholesterol gallstones. However, wedo notagreewiththeir recommendations for the investigation of suspected choledocholithiasis.If a patient has symptoms typical of gallstone disease and abnormal liver enzymes, the initial investigation should be abdominal ultrasonography. If the patient is not jaundiced and there are no other risk factors suggesting a need for a therapeutic procedure,2,3 the presence of dilated intrahepatic or extrahepatic ducts on ultrasonography should not lead directly to endoscopic retrograde cholangiopancreatography (ERCP) as Portincasa and colleagues recommended.ERCP is not a risk-free procedure, as was shown by a UK national audit, which revealed a complication rate of 5% and a procedure-related death rate of 0-4%.4 Magnetic resonance cholangiopancreatography (MRCP) or endoscopic ultrasonography are less invasive than ERCP and accurate in identifying common duct stones. Although they do not allow therapeutic intervention, they will allow many patients to avoid the risks of ERCP. In our own practice, the introduction of endoscopic ultrasonography has substantially reducedthenumberof patients requiring ERCP for gallstone disease. In a 52-month period, 134 patients who would previously have had an ERCP for gallstones were able to avoid it, and only 51 patients went on to ERCP after endoscopic ultrasonography.5Access to MRCP and endoscopic ultrasonography has been a problem, but they are becoming more widely available and current guidance would advise that they are used in preference to ERCP if the patient is at low risk of needing a therapeutic procedure.