Total Bilirubin Important Risk Factor for Pediatric Bile Duct Stones

Gallstones. Illustration showing the liver and gallbladder with gallstones. The gallbladder stores bile, the digestive fluid that is produced by the liver (above gallbladder) and passed to the small intestine. Gallstones, hard deposits formed of cholesterol and bile salts, form in the gallbladder when there is an imbalance in the chemical composition of the bile. Gallstones are usually symptomless, unless one obstructs the bile duct, causing acute pain, jaundice and infection. Treatment is with drugs to dissolve the stones or surgical removal of the gallbladder.
A team of investigators evaluated the performance of adult-based criteria for predicting common bile duct stones in children.

Pediatric common bile duct stones may be predicted with abdominal imaging and laboratory indices, according to findings from a prospective, multicenter study published in Gastrointestinal Endoscopy.

A team of investigators recruited 95 children (aged <19 years) undergoing endoscopic retrograde cholangiopancreatography (ERCP) at 8 international centers for suspected choledocholithiasis for the Pediatric ERCP Database Initiative (PEDI). They compared patients with (n=69) and without (n=26) common bile duct stones in this study.

When stones were present, they were identified and removed 72% of the time, and procedural success varied by site (ranging from 33% to 100%).

Patients were a median age of 13.9 years (interquartile range [IQR], 8.7-15.5); 81% were female, 88% were White, and 37% were obese. Patients found to have a stone more frequently had gallstone pancreatitis (50% vs 19%; P =.004).

In the 24 hours before ERCP, patients who had a stone removed were found to have higher total bilirubin (median, 2.8 vs 1.7 mg/dL; P =.02), direct or conjugated bilirubin (median, 1.5 vs 0.7 mg/dL; P =.02), and direct or conjugated bilirubin >2 mg/dL (32% vs 8%; P =.03) vs patients who did not have a stone removed.

At ERCP, patients who had a stone removed were more likely to undergo cholangiogram (88% vs 27%; P =.0001) rather than computed tomography (8% vs 75%; P =.03).

The best predictors of stones were direct or conjugated bilirubin ³2.3 mg/dL (odds ratio [OR] 8.3; 95% CI, 1.0-66.8; P =.05), ³2.1 mg/dL (OR 5.5; 95% CI, 1.2-25.5; P =.03), or ³1 mg/dL (OR 2.9; 95% CI, 1.1-1.8; P =.04).

Use of the American Society for Gastrointestinal Endoscopy 2019 high-risk criteria improved specificity to 91% and positive predictive value (PPV) to 86%; inclusion of direct or conjugated bilirubin ≥2.1 mg/dL was found to improve specificity to 92% and PPV to 91%.

This study was limited by the low sample size and high intracenter variability.

These findings suggest that bilirubin concentration obtained in the 24 hours before ERCP in addition to established adult risk factors may allow for improved risk stratification for pediatric common bile duct stones.


Fishman DS, Barth B, Man-Wai Tsai C, et al. A prospective multicenter analysis from the Pediatric ERCP Database Initiative: predictors of choledocholithiasis at ERCP in pediatric patients. Gastrointest Endosc. Published online February 1, 2021. doi:10.1016/j.gie.2021.01.030