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The role of endoscopy in the evaluation of suspected choledocholithiasis

    1. We recommend that the initial evaluation of suspected choledocholithiasis should include serum liver biochemical tests and a transabdominal US of the right upper quadrant. 444B These tests should be used to risk-stratify patients to guide further evaluation and management.
    2. We recommend that patients with symptomatic cholelithiasis who are surgical candidates and have a low probability of choledocholithiasis proceed to cholecystectomy without additional biliary evaluation.
    3. We recommend that patients with an intermediate probability of choledocholithiasis undergo further evaluation with preoperative EUS or MRC or an IOC. 444BIn this group of patients, we suggest that ERC be deferred unless EUS, MRC, and IOC are unavailable, given the less favorable risk profile of ERC.
    4. We recommend that patients with a high probability of choledocholithiasis undergo an evaluation of the bile duct with therapeutic capability, generally preoperative ERC. When available, laparoscopic bile duct exploration can serve as an alternative to ERC.
    5. We suggest that EUS or MRC be considered in the diagnostic evaluation of postcholecystectomy patients suspected of having choledocholithiasis when initial laboratory and US data are abnormal yet nondiagnostic.
    6. We recommend against early ERC in the evaluation and management of patients with mild ABP in the absence of clear evidence of a retained stone.
    7. We recommend early ERC in patients with acute biliary pancreatitis and concomitant cholangitis, given the observed benefits in morbidity and mortality.
    8. We suggest that patients with acute biliary pancreatitis and clinical evidence of biliary obstruction be considered for early ERC. We cannot recommend for or against early ERC in patients with predicted severe acute biliary pancreatitis in the absence of overt biliary obstruction or cholangitis, given the lack of consensus in the available data.
    9. As patients with acute biliary pancreatitis are at least at intermediate risk for choledocholithiasis, we suggest pre-operative EUS or IOC be considered for these patients when cholangitis or biliary obstruction are absent.