Total Bilirubin Is a Useful Predictor of Persisting Common Bile Duct Stone in Gallstone Pancreatitis TONY CHAN, M.D.,* AREZOU YAGHOUBIAN, M.D.,* DAVID ROSING, M.D.,* EDWARD LEE, B.S.,† ROGER J. LEWIS, M.D., PH.D.,‡§ BRUCE E. STABILE, M.D.,*§ CHRISTIAN DE VIRGILIO, M.D.*§ From the Departments of *Surgery and ‡Emergency Medicine, Harbor–UCLA Medical Center, Los Angeles, California; †David Geffen School of Medicine at UCLA, Los Angeles, California; and the §Los Angeles Biomedical Institute at Harbor–UCLA Medical Center, Los Angeles, California Accepted guidelines for preoperative endoscopic retrograde cholangiopancreatography (ERCP) in gallstone pancreatitis are lacking. Our previous investigations suggested that serum total biliru- bin on hospital Day 2 best predicts persisting common bile duct (CBD) stones. We aim to identify an optimal total bilirubin threshold on hospital Day 2 that would predict persisting CBD stones and guide obtaining preoperative ERCP. Prospective and retrospective data were available from 200 consecutive patients with gallstone pancreatitis at a public teaching hospital from 2003 through 2007. Charts were examined for persisting CBD stones on ERCP and/or intraoperative cholangiography during laparoscopic cholecystectomy. Patients with cholangitis (n = 18) were excluded. Nineteen of the remaining 182 (10%) patients had CBD stones. Mean hospital Day 2 bilirubin was 3.7 mg/dL for patients with CBD stones versus 1.4 mg/dL for those without (P < 0.0001). Seventeen patients (9%) had total bilirubin 4 or greater on hospital Day 2. Of these, eight (4%) had CBD stones (specificity 94%). Of the 165 patients with total bilirubin less than 4, 11 (7%) had CBD stones (P < 0.0001). In gallstone pancreatitis, a serum total bilirubin level 4 mg/dL or greater on hospital Day 2 predicts persisting CBD stones with enough specificity to serve as a practical guideline for ERCP while minimizing unnecessary procedures. G ALLSTONES ARE THE MOST common cause of acute pancreatitis. Current management of gallstone pancreatitis involves laparoscopic cholecystectomy performed before patient discharge to prevent future episodes of biliary obstruction and recurrent pancrea- titis. The management of suspected persisting com- mon bile duct (CBD) stones in gallstone pancreatitis has evolved over the past 2 decades with the advent of endoscopic retrograde cholangiopancreatography (ERCP), sphincterotomy, and stone extraction to re- lieve the biliary obstruction. Although investigators initially advocated routine early ERCP in all patients with gallstone pancreatitis, current views recommend selective use. 1–4 Recent studies suggest that ERCP may be most beneficial in patients with gallstone pan- creatitis with ongoing biliary obstruction. 5 However, practical guidelines on when to perform selective ERCP are lacking. Several studies have described indicators to identify persisting CBD stones in patients with gallstone pan- creatitis. In a retrospective study, Neoptolemos et al. 6 identified four variables: serum total bilirubin level greater than 40 mol (2.38 mg/dL), patient age older than 70 years, serum gamma-glutamyl transferase level greater than 250 IU/L, and serum alkaline phos- phatase level greater than 225 IU/L, which were asso- ciated with persisting CBD stones. In a more recent prospective study from our institution, only an el- evated serum total bilirubin level on hospital Day 2 was associated on multivariate analysis with the pres- ence of persisting CBD stones. 7 As determined by the receiver operator characteristic curve, a threshold greater than 1.35 mg/dL appeared to have the best predictive value. However, subsequent to this study, we have observed that this threshold appears to lack sufficient positive predictive value and, as such, we frequently were performing negative and unnecessary ERCP preoperatively. The purpose of the present study was to determine the optimal serum total biliru- Presented at the 19th Annual Scientific Meeting of the Southern California Chapter of the American College of Surgeons in Santa Barbara, CA, January 18–20, 2008. Address correspondence and reprint requests to Christian de Virgilio, M.D., 1000 W. Carson Street, Box 25, Torrance, CA 90509. E-mail cdevirgilio@labiomed.org. 977