The main objective was to assess the rate of EUS choledocholithiasis confirmation in patients with clinical suspicion of CBD stones and to identify predictors for choledocholithiasis. The secondary objective was to develop and internally validate a simplified clinical prediction score to refine risk stratification in patients with high-risk of choledocholithiasis according to the ESGE criteria.

We performed a retrospective study including patients who underwent EUS for suspected choledocholithiasis between January 2023 and December 2024 in a tertiary referral center.  Multivariate logistic regression was performed to identify independent predictors of retained CBD stones. A simplified score was constructed based of the final model. Internal validation of the score was performed through receiver operating characteristic (ROC) analysis. Sensitivity and specificity for candidate thresholds were obtained from ROC coordinates.

Of the 438 patients were evaluated for eligibility, 186 patients were included. 86 patients were diagnosed on EUS with choledocholithiasis and ERCP was performed. After ESGE criteria risk stratification, 10 patients (5.4%) were found to have a low risk for lithiasis, 92 (49.5%) were classified as having intermediate risk, and 84 (45.2%) met high-risk criteria. In the latter subgroup, EUS confirmed choledocholithiasis in 45 patients (53.5%), whereas 39 (46.4%) had spontaneous clearance of the CBD. Multivariate analysis identified acute pancreatitis (aOR 0.075, p < 0.001), cholangitis (aOR 6.939, p = 0.015), and CBD diameter (aOR 1.220 per mm increase, p = 0.027) as independent predictors of retained stones. A three-component score (range −2 to +4 points) was developed incorporating these variables. Internal validation showed a good accuracy of the score, with an AUROC of 0.788. A threshold of ≥2 points provided optimal performance, with a sensitivity of 85.7% and specificity of 59.0%. Higher thresholds increased specificity (e.g., ≥3 points: 89.7%) at the cost of reduced sensitivity.

In nearly half of the patients that presented high risk for choledocholithiasis according to ESGE criteria EUS did not confirm CBD stones, suggesting that routine ERCP in this subgroup should be carefully considered. Acute pancreatitis, cholangitis, and EUS-measured CBD diameter independently predicted retained stones and enabled the development of a simple prediction score with good internal discriminative performance. Incorporating EUS into the evaluation of ESGE high-risk patients, and applying refined risk stratification tools may improve diagnostic accuracy and help avoid performing ERCP without a clear benefit.