Diagnosis and treatment of acute calculus cholecystitis: WSES 2020 Guideline

Tools to Use for Suspicion and Diagnosis at Presentation

• The use of elevated LFTs or bilirubin is not recommended as the only method to identify CBDS (common bile duct stone) in patients with ACC, in which case we recommend performing further diagnostic tests.
  
• Consider the visualization of a stone in the common bile duct at transabdominal US as a predictor of CBDS in patients with ACC.
• An increased diameter of common bile duct, an indirect sign of stone presence, is not sufficient to identify ACC patients with CBDS and we therefore recommend performing further diagnostic tests.
• In order to assess the risk for CBDS, we suggest performing liver function tests (LFTs), including ALT, AST, bilirubin, ALP, GGT and abdominal US in all patients with ACC.
• Stratifying the risk of CBDS is suggested according to the proposed classification modified from the American Society of Gastrointestinal Endoscopy and the Society of American Gastrointestinal Endoscopic Surgeon Guidelines.
• The patients with moderate risk for CBDS are recommended to undergo one of the following: preoperative magnetic resonance cholangiopancreatography (MRCP), preoperative endoscopic ultrasound (EUS), intraoperative cholangiography (IOC), or laparoscopic ultrasound (LUS), depending on local expertise and availability.
• Patients with high-risk for CBDS are recommended to undergo preoperative ERCP, IOC or LUS, depending on the local expertise and the availability of the technique.
• Removing CBDS is recommended, either preoperatively, intraoperatively, or postoperatively, according to the local expertise and the availability of several techniques.