High Risk Factors For Recurrent Common Bile Duct Stone

Background: Common bile duct stone(CBDS) is a more common digestive disease. ERCP(endoscopic retrograde cholangiopancreatography) is the primary choice for the removal of CBDS. However, 4% to 24% of patients experience a recurrence after successful clearance of CBDS. Stone recurrence occurs more frequently in patients who undergo EST(endoscopic sphincterotomy) than endoscopic papillary balloon dilation(5.7%-26.7% vs. 1.6%-8.1%). Sphincter of Oddi damage after EST could lead to potential biliary infection and stone recurrence secondary to reflux of duodenal contents into the bile duct. Although it was believed that DBR was the important cause of CBDS recurrence, the direct evidence is still lacking. Proof of this relationship with the simplest way is an unresolved problem in clinical practice. Gastroesophageal reflux and constipation are the most common clinical symptoms. Gastroesophageal reflux caused by esophageal sphincter relaxation has some similarity to duodenal-biliary reflux, as well as the high risk factors, such as increased luminal pressure, lower gastrointestinal motility, postural change and anatomical problems. Constipation may also increase the risk of high luminal pressure. We suspect that symptoms of gastroesophageal-reflux and constipation can be the agent ofduodenal-biliary reflex. Symptoms of gastroesophageal-reflux and constipation can be used as primary indicators for high risk of CBDS recurrence.Aims:1) To investigate the DBR rate with recurrent CBDS using prospective case-control study. 2) To investigate the symptoms of gastroesophageal-reflux and constipation with recurrent CBDS using retrospective case-control study.Objects:A total of 264 patients with a history of stone removal by ERCP in Xijing Hospital were included in two studies. Part one study include 64 patients(32 with recurrent CBDS, 32 without recurrent CBDS); part two study include 200 patients(100 with recurrent CBDS, 100 without recurrent CBDS).Methods: All patients receive the standard barium meal examination, MRCP, and enhanced abdominal CT in part one study; all patients receive the questionnaires in part two study. Statistical analysis includes Fisher exact test, Student t test and logistic regression analysis.Results: 1) Baseline characteristics and parameters regarding the first ERCP were comparable between the 2 groups. The DBR rate was significantly higher in the recurrent than in the control group(68.8% vs. 15.6%, P <0.001). Multivariate analysis indicated that DBR(OR, 9.59; 95% CI, 2.65-34.76) and acute distal CBD angulation(OR, 5.48; 95% CI, 1.52-19.78) were independent risk factors associated with CBDS recurrence. DBR rates in patients with no, single, or multiple recurrences were 15.6%, 60.9%, and 88.9%, respectively(P<0.001). Intrahepatic bile duct reflux was more common in patients with multiple recurrences(66.7% vs. 10.9%, p<0.001). 2) Baseline characteristics and parameters regarding the first ERCP were comparable between the 2 groups. The rate of gastroesophageal-reflux and constipation was 21% vs. 17% and 15% vs. 16% in recurrent and control group, respectively(all p>0.1). Multivariate analysis indicated that distal CBD angulation ≤135°(OR, 3.07; 95% CI, 1.22-7.72) were independent risk factors associated with CBDS recurrence.Conclusions: 1) This study supplied the direct evidence that DBR is correlated with CBDS recurrence inpatients who had previously undergone ERCP. DBR and acute distal CBD angulation are two independent risk factors related to CBDS recurrence. 2) This study revealed that symptoms of gastroesophageal-reflux and constipation are not correlated with CBDS recurrence. Acute distal CBD angulation is an independent risk factor related to CBDS recurrence.