Choledocholithiasis (CDL) is a common indication for endoscopic retrograde cholangiopancreatography (ERCP). While guidelines use static hepatic biomarker values to estimate pre-test probability, the utility of trending these labs (bilirubin and alkaline phosphatase [ALP]) is unclear. It is unknown if improving biomarker trends reliably indicate stone passage and can help avoid unnecessary procedures.
To evaluate whether serial trends in hepatic biomarkers prior to ERCP can predict the presence of suspected CDL in hospitalized patients and guide decisions on ERCP referral.
We conducted a retrospective study of 198 patients undergoing ERCP for suspected CDL from 2002 to 2018. Patients were categorized based on biomarker trends, primarily into: Group 1 (normalized bilirubin with normalized ALP or ALP falling ≥ 50%) and Group 2 (all other patients). The primary outcome was the diagnostic yield of CDL on ERCP.
Among 198 patients, the yield of choledocholithiasis was not significantly different between Group 1 (69.5%) and Group 2 (71.2%) (p = 0.83). Even when redefining Group 1 as patients with "entirely normal hepatic biomarkers," the yield for stones was 55%. The diagnostic accuracy of the final lab values was poor, with an area under the curve of 0.57 for bilirubin and 0.51 for ALP. Patients in Group 1 had a significantly higher rate of post-ERCP pancreatitis (8.5% vs. 0%, p = 0.012) and a lower risk of septic shock.
Normalization or decline in hepatic biomarkers, such as bilirubin and ALP, does not reliably exclude CDL. Over half of the patients with normalized biomarkers were still found to have stones on ERCP. ERCP should be considered when suspicion remains high, regardless of laboratory trends.
Digestive diseases and sciences. 2026 May 29 [Epub ahead of print]
Zehra Naseem, Renan Prado, Arjun Chatterjee, Leandro Sierra, James Scott Ramey, Stephen Firkins, Akash Khurana, Roma Patel, John McMichael, James Bena, Moises Auron, Prabhleen Chahal, Roberto Simons-Linares
Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH, 44195, USA., Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH, 44195, USA. ., Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, OH, 44195, USA., Bethesda North, Montgomery, OH, 45242, USA., Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, 44195, USA., Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, 44195, USA., Department of Gastroenterology and Hepatology, University of Texas San Antonio, San Antonio, TX, 78229, USA., Department of Gastroenterology, Loyola University Medical Center, Maywood, IL, 60153, USA.