Evidence-based clinical practice guidelines for cholelithiasis 2021

JSGE · 2023 · Japan

Source and licence

Authors: Naotaka Fujita, Ichiro Yasuda, Itaru Endo et al.
Title: Evidence-based clinical practice guidelines for cholelithiasis 2021
Journal: Journal of Gastroenterology, 2023
DOI: 10.1007/s00535-023-02014-6
Licence: CC BY 4.0
Changes: Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC10423145

Licence statement of the original publication

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Recommendations

Verbatim, with grade of recommendation or strength of consensus where given.

Recommendation

EUS prior to ERCP is suggested in patients with suspected CBDS when other diagnostic images are indeterminate.
Cholecystectomy should be considered for patients at high risk of gallbladder cancer.
Laparoscopic cholecystectomy is recommended for symptomatic gallbladder stones.
Early cholecystectomy by a skilled surgeon is recommended in a tertiary medical institution for patients who have undergone surgery.
If a patient cannot withstand emergent/early surgery, early gallbladder drainage is recommended.

Recommendations

Percutaneous transhepatic gallbladder drainage (PTGBD) is recommended in cases of acute cholecystitis.
Endoscopic gallbladder drainage is proposed for patients with coagulopathy, patients receiving antithrombotic agents, and those with ascites by a skilled endoscopist.
Surgical treatment is recommended for the Mirizzi syndrome.
Endoscopic treatment with oral cholangioscopy at a well-equipped endoscopic institution is suggested for confluence stone.

Recommendation

Endoscopic treatment is recommended for CBDS that are uncomplicated by gallstones or with a history of cholecystectomy.
Stone removal is proposed for asymptomatic CBDS because of the risk of cholangitis and other complications.
Single-session stone removal can be safely performed in patients with CBDSs and acute cholangitis. Bile duct drainage only in the first session and scheduled stone removal are suggested depending on the patient's condition.
Early endoscopic treatment is suggested for biliary pancreatitis associated with acute cholangitis.
EPLBD is recommended for large or multiple bile duct stones.
For giant stones, endoscopic treatment with ESWL or POCS is performed at specialized centers; however, there is little evidence to support recommending its use.
Balloon endoscopy is proposed for CBDS removal by experienced surgeons in patients with post-surgically altered upper gastrointestinal anatomy.
(Recommendation: weak, 100% agreed, evidence level C).

CQ3-(2)-8 Is endoscopic treatment recommended for CBDS in patients receiving antithrombotic therapy?

Statement• Endoscopic treatment is recommended for CBDS in patients receiving antithrombotic therapy, as described in the relevant guidelines.

Recommendation

Balloon catheters are as useful as basket catheters in endoscopic stone removal for CBDS and both are recommended.
For CBDS with gallstones, cholecystectomy is recommended after endoscopic choledocholithotomy.
For CBDS without gallstones, there is a lack of evidence to recommend additional cholecystectomy after endoscopic choledocholithotomy.

Abstract

The Japanese Society of Gastroenterology first published evidence-based clinical practice guidelines for cholelithiasis in 2010, followed by a revision in 2016. Currently, the revised third edition was published to reflect recent evidence on the diagnosis, treatment, and prognosis of cholelithiasis conforming to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Following this revision, the present English version of the guidelines was updated and published herein. The clinical questions (CQ) in the previous version were reviewed and rearranged into three newly divided categories: background questions (BQ) dealing with basic background knowledge, CQ, and future research questions (FRQ), which refer to issues that require further accumulation of evidence. Finally, 52 questions (29 BQs, 19 CQs, and 4 FRQs) were adopted to cover the epidemiology, pathogenesis, diagnosis, treatment, complications, and prognosis. Based on a literature search using MEDLINE, Cochrane Library, and Igaku Chuo Zasshi databases for the period between 1983 and August 2019, along with a manual search of new information reported over the past 5 years, the level of evidence was evaluated for each CQ. The strengths of recommendations were determined using the Delphi method by the committee members considering the body of evidence, including benefits and harms, patient preference, and cost–benefit balance. A comprehensive flowchart was prepared for the diagnosis and treatment of gallbladder stones, common bile duct stones, and intrahepatic stones, respectively. The current revised guidelines are expected to be of great assistance to gastroenterologists and general physicians in making decisions on contemporary clinical management for cholelithiasis patients.

Contents of the original publication

The section headings of the original.

Introduction
Epidemiology and pathophysiology
BQ1-1. Is the prevalence of cholelithiasis increasing in Japan?
BQ1-2. What are the causes of cholecystolithiasis?
Statement
BQ1-3. What are the risk factors for gallbladder stones?
Statement
BQ1-4. What is the natural history of gallbladder stones?
Statement
CQ1-1. Is gallbladder stone a risk factor for gallbladder cancer?
Statement
Commentary
BQ1-5. Is hepatolithiasis a risk factor for intrahepatic cholangiocarcinoma?
Statement
Diagnosis
BQ2-(1)-1. What are the symptoms of gallbladder stones?
Statement
BQ2-(1)-2. How should the diagnosis of gallbladder stones be made?
Statement
BQ2-(1)-3. What about the diagnostic process of a patient with acute cholecystitis?
Statement
BQ2-(2)-1. What are the symptoms of CBDS?
Statement
BQ2-(2)-2. How are CBDS diagnosed?
Statement
CQ2-(2)-1. Is it recommended to perform EUS prior to ERCP rather than direct ERCP when abdominal US, CT, and/or MRI/MRCP are indeterminate in patients with suspected CBDS?
Recommendation
Commentary
Column 1: is it possible to differentiate between primary CBDS and secondary stones from the gallbladder?
BQ2-(3)-1. What are the symptoms of hepatolithiasis?
Statement
BQ2-(3)-2. How is hepatolithiasis diagnosed?
Statements
Treatment
BQ3-(1)-1. How should the treatment of patients with acute cholecystitis be applied?
Statement
BQ3-(1)-2. What are the nonsurgical treatments for cholecystolithiasis?
Statements
CQ3-(1)-1. Is cholecystectomy recommended over follow-up for asymptomatic patients with cholecystolithiasis?
Recommendation
Commentary
FRQ 3-(1)-1. Is cholecystectomy recommended in a case of gallbladder stones with an atrophic gallbladder?
Statement
Commentary
CQ3-(1)-2. Is cholecystectomy recommended over nonoperative treatment for symptomatic gallbladder stones?
Recommendation
Commentary
CQ3-(1)-3. Is early laparoscopic cholecystectomy for severe acute cholecystitis recommended over conservative treatment, including biliary drainage and administration of antibacterial agents?
Recommendation
Commentary
CQ3-(1)-4. Is endoscopic gallbladder drainage recommended over percutaneous transhepatic gallbladder drainage in acute cholecystitis?
Recommendations
Commentary
CQ3-(1)-5. Is endoscopic treatment recommended over surgery for the Mirizzi syndrome and confluence stone?
Recommendations
Commentary
BQ3-(2)-1. What kind of endoscopic treatments do we have for CBDS?
Statements
BQ3-(2)-2. What are the surgical treatments for CBDS?
Statement
BQ3-(2)-3. What are the treatment options for CBDS associated with gallbladder stones?
Statements
BQ3-(2)-4. Is endoscopic CBDS removal plus surgical cholecystectomy (two-stage combined treatment) more beneficial than surgical CBDS removal plus cholecystectomy (one-stage surgical treatment) for CBDS complicated with gallbladder stones?
Statement
FRQ3-(2)-1. Does surgical treatment for CBDS, which does not affect the function of the sphincter of Oddi, have a better long-term prognosis compared to that of endoscopic treatment?
Statement
Commentary
FRQ3-(2)-2. Is laparoscopic surgery recommended over open surgery for one-stage surgical treatment of CBDS with gallbladder stones?
Statement
Commentary
CQ3-(2)-1. For patients with CBDS uncomplicated with gallbladder stones or post-cholecystectomy, is endoscopic treatment recommended over surgery?
Recommendation
Commentary
CQ3-(2)-2. For asymptomatic CBDS, is stone removal recommended over follow-up without treatment?
Recommendation
Commentary
CQ3-(2)-3. Is single-session stone removal recommended in cases of bile duct stones with acute cholangitis?
Recommendation
Commentary
CQ3-(2)-4. Is endoscopic treatment recommended over conservative treatment for biliary pancreatitis?
Recommendation
Commentary
CQ3-(2)-5. Is EPLBD more recommended than EST for large or multiple bile duct stones?
Recommendation
Commentary
CQ3-(2)-6. Is endoscopic treatment recommended for giant CBDS?
Recommendation
Commentary
CQ3-(2)-7. In the case of CBDS with altered anatomy after upper gastrointestinal surgery, what kind of treatment should be selected for stone removal?
Recommendation
Commentary
BQ3-(2)-5. Is percutaneous transhepatic biliary drainage useful for acute cholangitis with CBDS when endoscopic transpapillary drainage is difficult?
Statement
BQ-3-(2)-6. What kind of patients with CBDS are good indications for EPBD?
Statement
CQ3-(2)-8 Is endoscopic treatment recommended for CBDS in patients receiving antithrombotic therapy?
Statement:
Commentary
CQ3-(2)-9 Is endoscopic stone removal recommended over permanent biliary stenting for CBDS in the elderly and in patients with serious underlying comorbidities?
Statement
Commentary
CQ3-(2)-10. Is a balloon catheter more useful than a basket catheter in endoscopic stone removal for CBDS?
Recommendation
Commentary
CQ3-(2)-11. Is cholecystectomy recommended over follow-up after endoscopic choledocholithotomy?
Recommendation
Commentary
FRQ3-(2)-3. Is oral administration of a choleretic after removal of CBDS more useful than no treatment?
Statement
Commentary
BQ3-(3)-1. What are the procedures for treating hepatolithiasis?
Statements
BQ3-(3)-2. What are the indications for hepatectomy in cases of hepatolithiasis?
Statements
CQ3-(3)-1. Is observation recommended for asymptomatic hepatolithiasis?
Statements
Commentary
BQ3-(3)-3. Is ESWL useful for the treatment of hepatolithiasis?
Statement
BQ3-(3)-4. Is peroral endoscopic treatment useful compared with percutaneous transhepatic cholangioscopic lithotripsy in cases of hepatolithiasis?
Statement
Prognosis and adverse events
BQ 4–1. What are the long-term complications after cholecystectomy for gallbladder stones?
BQ4-2. Does cholecystectomy impair digestive and absorptive function?
Statement
BQ4-3. Are residual stones a risk factor for acute cholangitis and liver abscess after removal of CBD or intrahepatic stones?
Statement
BQ4-4. What are the long-term complications after treatment of CBDSs?
Statement
BQ4-5. What are the long-term complications after treatment of hepatolithiasis?
Statement
Appendix 1

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