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      A clinician's guide to gallstones and common bile duct (CBD): A study protocol for a systematic review and evidence‐based recommendations

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          Abstract

          Background and Aims

          Gallstones are one of the most common and costly diseases of the gastrointestinal tract and occur when a combination of deposits consisting of fat or minerals accumulate in the gallbladder or common bile duct (CBD). This paper provides a comprehensive review of gallstone epidemiology, diagnosis, and management, focusing on current clinical guidelines and evidence‐based approaches.

          Methods

          A systematic literature review gathered information from various sources, including PubMed, Trip, Google Scholar, Clinical Key, and reputable medical association websites. Keywords related to gallstones, CBD stones, cholelithiasis, choledocholithiasis, and guidelines were used to extract relevant recommendations. Expert consultations and consensus meetings localized the recommendations based on the target population and available resources.

          Results

          The paper discusses demographic factors, dietary habits, and lifestyle influences contributing to gallstone formation. Gallstones are categorized into cholesterol and pigment types, with varying prevalences across regions. Many individuals with gallstones remain asymptomatic, but complications can lead to serious and potentially life‐threatening conditions. Diagnosis relies on history, physical examination, laboratory tests, and transabdominal ultrasound. Specific predictive factors help categorize patients into high, moderate, or low probability groups for CBD stones.

          Conclusion

          Evidence‐based recommendations for gallstone diagnosis and management are presented, emphasizing individualized treatment plans. Surgical interventions, nonsurgical treatments like oral litholysis with UDCA, and stenting are discussed. The management of gallstones in pregnant women is also addressed, considering the potential risks and appropriate treatment options during pregnancy.

          Key points

          • Gallstones are a prevalent and costly gastrointestinal disease caused by fat or mineral deposits in the gallbladder or common bile duct (CBD).

          • This paper reviews gallstone epidemiology, diagnosis, and management based on clinical guidelines and evidence.

          • Predictive factors help categorize patients into high, moderate, or low risk for CBD stones.

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          Most cited references38

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          Endoscopic management of common bile duct stones: European Society of Gastrointestinal Endoscopy (ESGE) guideline

          Main Recommendations ESGE recommends offering stone extraction to all patients with common bile duct stones, symptomatic or not, who are fit enough to tolerate the intervention. Strong recommendation, low quality evidence. ESGE recommends liver function tests and abdominal ultrasonography as the initial diagnostic steps for suspected common bile duct stones. Combining these tests defines the probability of having common bile duct stones. Strong recommendation, moderate quality evidence. ESGE recommends endoscopic ultrasonography or magnetic resonance cholangiopancreatography to diagnose common bile duct stones in patients with persistent clinical suspicion but insufficient evidence of stones on abdominal ultrasonography. Strong recommendation, moderate quality evidence. ESGE recommends the following timing for biliary drainage, preferably endoscopic, in patients with acute cholangitis, classified according to the 2018 revision of the Tokyo Guidelines: – severe, as soon as possible and within 12 hours for patients with septic shock – moderate, within 48 – 72 hours – mild, elective. Strong recommendation, low quality evidence. ESGE recommends endoscopic placement of a temporary biliary plastic stent in patients with irretrievable biliary stones that warrant biliary drainage. Strong recommendation, moderate quality of evidence. ESGE recommends limited sphincterotomy combined with endoscopic papillary large-balloon dilation as the first-line approach to remove difficult common bile duct stones. Strong recommendation, high quality evidence. ESGE recommends the use of cholangioscopy-assisted intraluminal lithotripsy (electrohydraulic or laser) as an effective and safe treatment of difficult bile duct stones. Strong recommendation, moderate quality evidence. ESGE recommends performing a laparoscopic cholecystectomy within 2 weeks from ERCP for patients treated for choledocholithiasis to reduce the conversion rate and the risk of recurrent biliary events. Strong recommendation, moderate quality evidence.
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            Epidemiology of Gallbladder Disease: Cholelithiasis and Cancer

            Diseases of the gallbladder are common and costly. The best epidemiological screening method to accurately determine point prevalence of gallstone disease is ultrasonography. Many risk factors for cholesterol gallstone formation are not modifiable such as ethnic background, increasing age, female gender and family history or genetics. Conversely, the modifiable risks for cholesterol gallstones are obesity, rapid weight loss and a sedentary lifestyle. The rising epidemic of obesity and the metabolic syndrome predicts an escalation of cholesterol gallstone frequency. Risk factors for biliary sludge include pregnancy, drugs like ceftiaxone, octreotide and thiazide diuretics, and total parenteral nutrition or fasting. Diseases like cirrhosis, chronic hemolysis and ileal Crohn's disease are risk factors for black pigment stones. Gallstone disease in childhood, once considered rare, has become increasingly recognized with similar risk factors as those in adults, particularly obesity. Gallbladder cancer is uncommon in developed countries. In the U.S., it accounts for only ~ 5,000 cases per year. Elsewhere, high incidence rates occur in North and South American Indians. Other than ethnicity and female gender, additional risk factors for gallbladder cancer include cholelithiasis, advancing age, chronic inflammatory conditions affecting the gallbladder, congenital biliary abnormalities, and diagnostic confusion over gallbladder polyps.
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              Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis.

              We propose a new flowchart for the treatment of acute cholecystitis (AC) in the Tokyo Guidelines 2018 (TG18). Grade III AC was not indicated for straightforward laparoscopic cholecystectomy (Lap-C). Following analysis of subsequent clinical investigations and drawing on Big Data in particular, TG18 proposes that some Grade III AC can be treated by Lap-C when performed at advanced centers with specialized surgeons experienced in this procedure and for patients that satisfy certain strict criteria. For Grade I, TG18 recommends early Lap-C if the patients meet the criteria of Charlson comorbidity index (CCI) ≤5 and American Society of Anesthesiologists physical status classification (ASA-PS) ≤2. For Grade II AC, if patients meet the criteria of CCI ≤5 and ASA-PS ≤2, TG18 recommends early Lap-C performed by experienced surgeons; and if not, after medical treatment and/or gallbladder drainage, Lap-C would be indicated. TG18 proposes that Lap-C is indicated in Grade III patients with strict criteria. These are that the patients have favorable organ system failure, and negative predictive factors, who meet the criteria of CCI ≤3 and ASA-PS ≤2 and who are being treated at an advanced center (where experienced surgeons practice). If the patient is not considered suitable for early surgery, TG18 recommends early/urgent biliary drainage followed by delayed Lap-C once the patient's overall condition has improved. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.
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                Author and article information

                Contributors
                md.azadbakht.s@gmail.com
                Journal
                Health Sci Rep
                Health Sci Rep
                10.1002/(ISSN)2398-8835
                HSR2
                Health Science Reports
                John Wiley and Sons Inc. (Hoboken )
                2398-8835
                12 September 2023
                September 2023
                : 6
                : 9 ( doiID: 10.1002/hsr2.v6.9 )
                : e1555
                Affiliations
                [ 1 ] Department of Internal Medicine School of Medicine, Al‐Zahra Hospital, Isfahan University of Medical Sciences Isfahan Iran
                [ 2 ] Department of Internal Medicine School of Medicine, Lorestan University of Medical Sciences Khorramabad Iran
                Author notes
                [*] [* ] Correspondence Saleh Azadbakht, Lorestan University of Medical Sciences, Khorramabad, Iran.

                Email: md.azadbakht.s@ 123456gmail.com

                Author information
                http://orcid.org/0009-0000-0272-5636
                http://orcid.org/0000-0002-7679-2193
                Article
                HSR21555
                10.1002/hsr2.1555
                10496460
                37706014
                013fa846-c1e6-4bdb-98cb-da6ee0263ea5
                © 2023 The Authors. Health Science Reports published by Wiley Periodicals LLC.

                This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

                History
                : 01 August 2023
                : 08 June 2023
                : 29 August 2023
                Page count
                Figures: 2, Tables: 6, Pages: 13, Words: 7751
                Categories
                Gastroenterology/Hepatology
                Pharmacology and Pharmacy
                Cardiology
                Endocrinology and Metabolic Disorders
                Hematology
                Addiction and Analgesia
                Immunology
                Infectious Diseases
                Medical Education
                Study Protocols
                Study Protocols
                Custom metadata
                2.0
                September 2023
                Converter:WILEY_ML3GV2_TO_JATSPMC version:6.3.3 mode:remove_FC converted:12.09.2023

                bile duct,cholecystectomy,endoscopic,gallbladder,gallstones
                bile duct, cholecystectomy, endoscopic, gallbladder, gallstones

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