Clinical Outcomes of Endoscopic Treatment for Asymptomatic and Symptomatic Common Bile Duct Stones: Incidence and Risk Factors for Post-ERCP Pancreatitis.

Background/Objectives: Endoscopic retrograde cholangiopancreatography (ERCP) is the standard treatment for common bile duct stones (CBDSs). Current clinical guidelines recommend ERCP irrespective of symptom status. However, accumulating evidence suggests that patients with asymptomatic CBDSs are at an increased risk of post-ERCP pancreatitis (PEP). This study aimed to compare the incidence of PEP between patients with symptomatic and asymptomatic CBDSs and to identify independent risk factors for PEP. Methods: A total of 660 patients with a native papilla who underwent ERCP for CBDSs were retrospectively analyzed. Patients were stratified into symptomatic (n = 468) and asymptomatic (n = 192) groups. The incidence of PEP and its associated risk factors were compared between groups. Results: The incidence of PEP was significantly higher in the asymptomatic than symptomatic group (9.4% vs. 4.5%; p = 0.03). This difference was driven primarily by an increased incidence of mild PEP (6.2% vs. 2.4%; p = 0.02), whereas the rates of moderate and severe PEP were comparable. Pancreatic guidewire-assisted biliary cannulation was more frequent in the asymptomatic group (17.7% vs. 10.3%; p = 0.01) and emerged as an independent predictor of PEP. The asymptomatic group also achieved a significantly higher complete stone removal rate than the symptomatic group (99.0% vs. 95.3%; p = 0.02). Conclusions: ERCP for asymptomatic CBDSs was associated with a higher risk of PEP, primarily mild cases, but yielded favorable stone-related treatment outcomes. Therefore, ERCP is an acceptable treatment for asymptomatic CBDSs when the potential benefits and risks are thoroughly discussed with the patient beforehand.