Referral for ERCP with Gallstone Disease

1) Patients with cholecystolithiasis should be referred for an ERCP if:

• stone is seen in the CBD on u-sound
• biliary dilatation (CBD >7mm) & raised bilirubin
• biliary dilatation & raised ALP/GGT (these patients should be discussed when the ERCP is booked)

2) Patients who have gallstones with raised canalicular enzymes without biliary dilatation or jaundice

• have an increased probability of CBD stones  (about 15-25%)
• should have on-table cholangiogram.
• If it is technically impossible to perform an on-table cholangiogram, proceed with a cholecystectomy. The cystic duct needs to be well secured - a haemolock clip is usually the easiest way to do this.
• no stone is identified on the cholangiogram or if no cholangiogram was performed then the LFT's need to be checked one month after the cholecystectomy.
• If the LFT's have not returned to normal then they should be discussed with HPB, and consider MRCP looking for a CBD stone or other biliary abnormalities such as primary sclerosing cholangitis.

3) If a patient with gallstones is jaundiced without biliary dilatation

• medical cause needs to be excluded
• more likely if the AST/ALT are elevated but cholestatic liver disorders can also cause isolated raised cannilicular enzymes.
• An MRCP is often useful in excluding a stone in this situation.
• Discuss with HPB Unit
• If the hepatitis screen is negative, plan liver biopsy/hepatology referral
• cholecystectomy is usually not indicated